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Boston  University 


SCHOOL  OF 
SOCIAL  WORK 


LIBRARY 
Gift  of 


Digitized  by  the  Internet  Archive 
in  2014 


https://archive.org/details/studyofprehospitOOreag 


BOSTON  UNIVERSITY 
SCHOOL  CF  SOCIAL  WORK 


A  STUDY  OF  PRE-HOSPTTAL  PLANNING  AFFECTING 
HOSPITAL  ADJUSTMENT  OF  THE  TUBERCULOUS 
VETERAN 


A  thesis 


Submitted  by 
I'larguerite  Helen  Reagan 
(A.B.,  Union  College,  1949) 
In  Partial  Fulfillment  of  Requirements  for 
the  Degree  of  Master  of  Science  in  Social  Service 

1954 


BOSTON  UNIVERSITY 
SCHOOL  OF  SOCIAL  WORK 
LIBRARY 


Page 


List  of  Tables  Hi 
CHAPTER 

I.        Introduction    1 

Method  and  Scope    2 

Limitations    2 

II.        Social  Service  iu  tha  Veterans 

Administration    4 

History    4 

Chest  Clinic   6 

Eli£;ibility   7 

Referrals    7 

Function  of  Social  worker    8 

Pre-Hospital  Phase    8 

Hospital izatiou  Phase    13 

Post-Hospital  Phase    I5 

III.        Social  and  Emotional  Implications 

of  Tuberculosis   17 

Tuberculosis  and  Treatment    17 

Emotional  Shock  of  Diagnosia     ....  19 

Tuberculosis  and  Personality     ....  22 

Socio-Ecoiiomic  Factors    24 

ILffect  on  the  Family   26 

Meaning  of  Hospitalization    27 

IV.        Problems  in  Pre-Hospital  Planning     ...  29 

Samples  of  Cases  Studied    29 

Problems  .^risin^  Prior  to 

Hospitalization    38 

Attitude  toward  Illness    39 

Alcoholism   42 

Filing  a  Claim   43 

Financial  Problems    43 

Housing  Problems    44 

Interpretation  to  and  Support  of 

Families    45 

Personality  Proolems    47 


"AW 


TABLE  OF  CONTElvTS  (continued) 

Page 

CHAPTER 


V.        Description  of  Veterans  Studied  ....  49 

«.ge   49 

Karital  Status    5I 

Occupation  Prior  to  Hospitalization  52 

Finances   52 

Referral  for  Hospitalization  ....  54 

Type  of  Hospital  Discharge   55 

VI.        Summary  auo  Conclusions   58 

Appendix   53 

Bibliography    54 


LIST  OF  TABL3S 

TABLE  PAGE 

I-     Ace   50 

II.    Marital  Status   52 

III.     Financial  Status   54 

IV.    Hospital  Discharge   55 


CriAFTER  I 
INTRODUCTION 

If  rehabilitation  begins  at  the  point  of  diagnosis  of 
an  illness,  then  the  role  of  the  social  worker  with  tubercu- 
lous patients  is  extremely  important  in  the  pre-hospital  plan- 
ning period  as  she  sets  the  stage  and  helps  the  tuberculous 
patient  choose  the  role  he  will  play  in  the  future  in  regard 
to  his  newly  discovered  disease. 

One  of  the  most  disconcerting  factors  in  the  study  of 
tuberculous  patients  is  the  high  rate  of  irregular  hospital 
discharges.    Although  this  study  will  not  develop  this  fac- 
tor,  it  is  important  to  grasp  the  extent  of  this  problem  in 
order  to  recognize  the  need  of  studying  every  phase  of  treat- 
ment of  the  tuberculous  patient.    Only  thus  can  we  hope  to 
curb  irregular  discharges  so  prevalent  in  this  group. 

.   .   .   studies,  together  with  the  observations 
of  numerous  authorities,  indicate  that  irregular 
discharge  is  almost  universally  a  characteristic 
phenomenon  of  hospitalization  for  tuberculosis  in 
this  country. 

In  1947  the  rate  of  irregular  discharges  from  Veterans 
Administration  hospitals  of  tuberculous  patients  was  5^.4 
per  cent,  and  only  45.6  per  cent  were  regular  discharges.^ 


1  •rilliam  B.  Tollen,  Irregular  Discharge;  The  Prob- 
lem of  Hospitalization  of  the  Tuberculous ,  Veterans  Adm i n i s - 
tration,  1945",  p.  4. 

2  Ibid.,  p.  1. 


Method  and  Scope 
This  study  focused  on  those  veterans  who  were  referred 
by  the  physicians  of  the  Boston  Regional  Office  Chest  Clinic, 
Veterans  Administration,   to  the  Social  Service  Unit  for  pre- 
hospital planning.     The  case  material  was  dependent  on  social 
service  case  records.    From  the  large  number  of  tuberculous 
veterans  seen  by  the  Social  Service  Unit  in  1951,  twenty- 
seven  cases  were  chosen.     The  majority  of  the  cases  referred 
to  the  Social  Service  Unit  followed  the  initial  diagnosis 
of  tuberculosis.    Although  some  of  the  cases  were  of  veterans 
who  had  previously  had  tuberculosis,  this  was  their  first  con- 
tact with  social  service  at  the  Veterans  Administration  Boston 
Regional  Office  for  pre-hospital  planning.     Because  of  the 
nature  of  the  illness  which  requires  long  periods  of  hospi- 
talization, cases  were  chosen  in  which  hospital  referral  was 
initiated  during  the  year  of  1951.     This  was  deemed  necessary 
in  order  that  enough  time  would  have  elapsed  so  that  informa- 
tion would  be  available  in  regard  to  hospital  adjustment  and 
discharge.     Cases  were  also  selected  on  the  condition  that 
hospital  referral  resulted  in  Veterans  Administration  hospi- 
talization. 

Limitations 

The  first  limitation  was  the  varying  amount  of  case 
material  available  among  the  cases  chosen  for  this  study.  In 
the  majority  of  pre-hospital  records,   social  service  contact 


was  limited  to  one  interview.    Many  reasons  accounted  for  this 
short  contact,   the  most  important  being;  the  nature  of  the  ill- 
ness and  the  doctor's  usual  recommendation  for  as  complete 
bed  rest  as  possible  pending  hospitalization  or,  as  in  some 
cases,  an  eraers^ency  hospital  referral.     In  studying  hospital 
social  service  records  material  was,   in  some  cases,  limited 
to  initial  hospital  admission  notes  on  an  index  card  with 
correspondingly  brief  evaluations  of  hospital  adjustment  and 
discharge.     In  a  very  few  cases  there  was  no  material  availa- 
ble on  hospitalization  in  the  social  service  records.  However, 
evaluations  were  secured  from  the  vocational  counselor  and 
doctors.     Since  these  veterans  received  regular  discharges 
it  was  assumed  that  hospital  adjustment  was  adequate,  and  this 
conclusion  tallied  with  the  pre-hospital  planning  evaluation. 
In  view  of  these  limitations  in  regard  to  hospital  records, 
any  evaluations  of  adjustment  would  not  have  been  entirely 
adequate. 


!|  4 

CHAPTER  II 

SOCIAL  SERVICE  IN  THE  VETERANS  aBUNI  STRATI  ON 
The  Veterans  Administration  has  been  set  up  under  the  jj 
auspices  of  the  United  States  Government  for  the  purijose  of 
adiTiinlsteriu^  the  benefits  provided  by  law  to  veterans,  their 
dependents,  and  beneficiaries.^ 

'rfith  headquarters  in  Washinp^ton,  D.C.,   the  Veterans  Hdmin-i| 
istx-Lition  operates  a  highly  complex  pro£;ram  by  an  intricate 
system  of  organization.     In  oruer  to  facilitate  this  program,  | 
the  Veterans  iidininistrs  t i  on  has  divided  the  United  States  into  | 
six  ^reas,   each  Area  i^tcVi.;,.^  its  ov<.i  ni  c.^,  uxxxe-e.     Under  the 
Area  Offices,   the  territory  covered  has  been  divided  into  Re- 
piona]  Areas.     The  Eostor  Regional  Office,   with  which  tViis 

I 

stUQV  was  conci  i-L..  cd,   cuvers  all  of  i-c^s  toctcliUbet  t  s  except  for  I 
the  southeastern  section  of  the  state.     The  Boston  Regional 
Office  is  only  ons  of  the  sixty-two  Re£;lona]  Offices  in  the 
United  States.     The  Boston  Regional  Office  Is  cuiL.od  in  ct^rrying; 
out  its  program,  of  which  comprehensive  medical  care  is  a  part, 

by  three  Veteraijs  administration  Sub-Regional  Offices  located  \ 

I 

in  Springfield,   iiorcestej-  ,  and  Lowell.     ihis  study  was  con-  j 
ceriied  with  the  Sub-Regional  Offices  only  in  that  they  referred' 
chest  pcitients  to  the  Boston  Regional  Office,   which  was  re- 
sponsible for  all  chest  CKses  in  tiie  veteran  population  in 
Massachus  :-t ts  which  were  service  connected. 

1  Functions  of  Veterans  Adjiilr'i st ration,  p.  1. 


ii 

Tiri!  OL.^  Llou  I   I'uzj  country  there  ^.x  e  one  hundred  and  fifty 
Veterans  Administration  hospitals,  nineteerj  of  which  special- 
ize in  tuberculosis.     In  the  oases  used  for  this  studv,  the 
'iictj ority  of  veterans  were,  hospitalized  at  the  r^utiau-.  xiei^Lts 
Veterans  Administration  Hospital,  Rutland,  Massachusetts,  and  ' 
the  n^inorlty  ;-.t  the  Cushintj  Veterans  administration  Hospital, 
Fraiiil a^uov.ij ,  i-.ciS3ci,CiiU;iet t s,  novi  closed.' 

The  social  service  program  was  established  in  the  Veterans, 
Administration  "in  the  recognition  that  effective  medical  care  ' 
, includes  the  treatment  of  the  social  factors  involved  in  ill- 
ness and  disabilities. "2  { 

i 

Un'er  the  total  Veterans  Administration  program,  thirteen 

hundred  social  workers  are  employed.     In  the  Boston  Regional 

Office  there  are  twenty-eight  social  workers;  one  half  in  the 

General  Ne-'ical  Section  rr.''  the  balance  in  the  Kental  Hygiene 

Unit,   two  Important  divisions  in  the  regional  Office.  Social 

service  within  the  Veterans  Administration  per  se  consists  of 

both  -'16  "leal  an-l  psychiatric  social  work. 

The  purpose  of  Social  Service  is  to  enable  the 
veteran  to  cope  with  those  factors  and  interrelation- 
ships which  are  destructive  and  develop  those  which 
will  be  constructive,   in  his  effort  to  recover  from 
illness,   lessen  handicap,  adjust  to  remaining  disabil- 
ity, and  re-establish  himself .5 

Hore  specif i caj.ly,    social  work^i  t  ^.^^  coiACcrncj^i  ,.ith  some 

2  Veterans  administration, "Technico-l  Bulletin,  T.B.," 
lOA-198,  1949. 

3  Ibid. 


of  the  following  areas  of  service:     assistance  to  the  veteran 
in  relation  to  entering;  upon  a  medical  care  re£;ime;  tLose  under 
care  in  the  out-patient  clinics  and  in  hospitals;  those  in  the 
process  of  leaving  the  hospital  or  domiciliary  care;  those 
veterans  on  trial  visits;  assistance  to  those  veterans  dis- 
charged from  active  medical  treatment;  and.  those  receiving 
vocational  rehabilitation  services.     Assistance  is  also  given 
to  the  phj'sician  in  securing  and  evaluating  social,  environ- 
mental, and  emotional  data,  as  well  as  to  other  departments 
with  the  Boston  Regional  Cffice.^ 

Chest  Clinic 

This  study  was  mainly  concerned  with  the  services  pro- 
vided by  the  Veterans  Administration  to  the  tuberculous  veter- 
aii  cit  the  Chest  Clinic,  Boston  Regional  Office. 

In  October,  1953,  the  Chest  Clinic  provided  medical  ser- 
vice to  2,338  service  connected  veterans  with  tuberculosis  and 
an  increase  was  exfjected  in  the  case  load  with  the  return  of 
the  Korean  Veteran.     Limited  service  was  also  given  to  the  non- 
service  connected  veteran  who  was  not  included  in  the  above 
number. 

The  staff  of  the  Chest  Clinic  was  comprised  of  the  chief 
physician,  two  doctors,   two  clerks,  a  nurse,  a  consultant  dieti* 
cian,  and  a  medical  social  worker. 


4  Ibid. 


Eli.  Ibillty; 

The  factors  governing  eligibility  in  relation  to  the  Chesti 
Clinic  are  as  follows:  ^ 

1.  Veterans  with  service  connection  for  tuberculosis 

are  eli^-ible  for  out-patient  treatment.  i| 

2.  Veterans,   regardless  of  service  connect ioij,  are 
eligible  for  diaf^nostic  studies,  and  hospitaliza- 
tion if  indicated.  I 

3.  All  veterans,  regardless  of  service  conuection, 

are  eligible  for  social  service  assistance.  ! 

4.  Veterans  may  be  referred  by  Vocational  Rehabili- 
tation and  Education  to  determine  medical  feasi- 
bility. 5 

hii^ai   Li  :  .-  two        t  .LOiic; c.ovc,  non-servic-3  covi.iec  I. veterans 
are  eligible  for  these  benefits  only  when  there  is  a  question 
of  need  for  hospitalization.     Also,  under  item  three,  non- 
service  connected  veteians  c*re  eliv  lbl«  loi   ii--iieo.io.tc  social 
service  help  only.     Vfhere  long-term  social  service  assistance 
to  the  non-service  connected  veteran  is  indicated,   referral  is 
made  to  an  appropriate  community  agency. 
Referral s ; 

Veter  c^.ns  are  referred  to  the  Chest  Clinic  from  Veterans 
Administration  hospitals,  from  the  many  jivisions  withivi  the 
Veterans  Administration,   such  as  the  Arthritic  Clinic,  the 
le^?"'  rivslon,  ?h^-i.bi1it'- 1 '  -^r"  Bo'-  rd;  or  they     r e  re- 

fen  eu  1  rom  jjiivatc  ox    ^aul-ic  nosj^  i  tals .     referrals  axso  come 
from,  individuals  in  the  community,  through  self -referral,  and  | 
from  c O"-? 'Unity  cies  both  public  a:  "  yr iv-  te. 


5  Veterans  Administration,  Operation  of  Tuberculosis 
Section,  Medical  Livision,  Boston  Regional  Office,  ]949. 


Function  of  Social  <i^orker; 

1.  The  Social  Service  Unit  is  responsible  for  case  j 
v\^ork  services  to  tuberculous  veterans  and  their  i 
families . 

2.  Social  work  involves  work  with  the  physician, 
rehabilitation  department,   and  outside  health 
and  social  agencies  in  order  to  insure  a  sound 
medical-social  plan,   which  will  enaole  the 
veteran  to  obtain  maximum  benefits  from  medical 
care,  and  to  make  the  best  possible  adjustment 
within  his  physical  limitations.^ 

Comprehensive  :iie;^ica!l   service  to  the  tuberculous  veteran 

can  be  divided  into  three  phases:  pre-hospital,  hospital,  and  i 

post-hospital. 

I 

Pre-Hospitctl  ^■'.iz.-^e 
Any  social  worker  whose  responsibility  is  service  to 
tuberculosis  patients  should  first  of  all  be  thorous'hly  cojni-  'I 
zant  of  the  ty^^e  oi'  xx_^iic-ss,   its  soci.c.j.  e.uot iouc;,!  iuij-Iica- 

tions,  and  the  medical  recommendations  for  treatment.  Even 
thoui^h  a  patient  may  appear  to  understai.d  whet  is  told  him  by  j 
the  doctor  &t  the  tiu-e  of  diagnosis,   often  tue  suoca  of  the 
disease  clouds  his  mind  ana  ability  to  absorb  correctly  what 

j 

has  been  se.id.  He  then  often  i  not  :-.ble  to  p  1  an  res  li  st i cally] 
toward  hospi tctlizat ion  without  help. 

From  a  social  case  work  standpoint,   the  time  limitation 
inherent  in  workln     .-rlth  tuberculous  ^    L  .ents  in  pre-hospital  ' 

i 

planning  is  a  necessc^ry  evil.  Necessary,  oecause  ^^s  a  facili-  j 
tator  of  medical  treatment  recogniziij^.  the  danger  of  spread  of  ll 


o  Veterans  AdJijlni  strati  on.   Social  Service  Intake 
Procedure,  Boston  Regional  Cfrice. 


infection  aad  the  need  for  rest,   interviewing  must  be  limited 
to  as  few  contacts  as  is  abso]ute]y  necessary  to  sj^et  the  pa- 
tient into  the  nospital.     There  is  no  time  to  explore  feelings 
on  a  long  term  basis.     Evaluations  must  be  made  immediately 
and  planning  started  as  soon  as  the  diagnosis  is  revealed  and 
the  referral  for  hospitalization  made,    ks  a  result  the  pre- 
hospital social  worker  cannot  be  completely  responsible  for 
working  through  a  patient's  feelings  and  attitudes  toward  this 
cri  sis . 

Howevi^r,   in  the  pre-hospital  planning  period  one  of  the 
main  values  of  social  service  is  that  of  providing  an  oppor- 
tunity to  the  veteran  to  express  what  his  illness  means  to 
hira,  his  understanding  of  his  illness  and  of  the  doctor's 
medical  recommendations.     It  is  felt  that  if  he  can  do  that  at 
the  time  of  diagnosis  many  exaggerated  fears  and  misinterpreta-i 
tions  can  be  ironed  out,  and  armed  with  the  support  and  en- 
couragement of  the  social  worker  he  will  be  more  able  to  face 
hospitalization  with  less  social  and  emotional  pressure. 

Cynthia  Rice  Nathan,  out  of  a  three  year  extensive  study 
of  pre-hospital  planning  with  the  tuberculous  veteran  iu  the 
Washington  Regional  Office  of  the  Veterans  Administration, 
presents  the  following  points  to  be  covered  at  a  minimum  during 
tne  pre-hospital  pla.i  .        interview. 7 

7  Cynthia  R.  Nathan,   "Clinic  Casework  in  a  Mass  Tuber- 
culosis Survey,"  Casework  iipcroach  to  Health  Jrroblems.  1949, 


First,   the  patient   should  be  i^;iven  the  opportunity  to  | 
express  what  the  diagnosis  of  tuberculosis  and  the  medical  re- 
commendations mean  to  him.     Second,   one  should  elicit  what 
the  patient's  understanding-  of  tuberculosis  is  and  why  hospi- 
talization was  recommended.     Third,   the  social  worker  should 
make  clear  at  the  start  her  willingness  to  help  with  any  prob- 
lems that  might  Jelay  or  carry  over  into  hospitalization  and, 
at  the  same  tluc,   iiiuire  into  the  patient's  home  conditions 
and  how  his  family  might  manage  in  his  absence.     Fourth,  the 
importance  of  not  leaving  the  hospital  until  maximum  hospital 
benefit  has  been  reached  should  be  thoroughly  explained  and 
made  clear.     Fifth,   the  patient  should  be  told  of  the  casework 
services  available  to  him  from  the  hospital  social  worker. 
Sixth,   the  reasons  for  --w-ray  of  "contacts"  should  be  reviewed 
and  information  given  as  to  the  location  of  public  health  j 
clinics  where  this  can  be  done.     Seventh,   if  the  nurse  does  nol 
review  with  the  patlei.;t  the  precaatlons  he  is  to  take  pending 
hospitalization,   this  should  be  done  by  the  social  worker. 
Eighth,   the  location  of  the  hospital  should  be  explained  so 
that  the  patient  will  understand  how  far  from  hoiae  he  will  oe. 
Ninth,   disability  benefits  to  which  the  veteran  may  be  entitled 
should  be  explored  with  him  as  in  the  Veterans  administration 
most  patients  are  or  will  be  eligible  for  financial  benefits. 
Tenth,   the  patient  should  be  given  the  social  worker's  name, 
telephone  number  and  address  so  that  he  will  feel  free  to 


11 


contact  the  social  worker  should  he  need  further  help  prior 
to  hospitalization. 

All  the  points  listed  above  are  usually  covered  in  the 
Boston  Regional  Office. 

Appointments  for  the  Chest  Clinic  are  made  through  the 
Medical  Appointment  Desk  of  the  Boston  Regional  Office.  In 
general  all  veterans  are  given  a  medical  examination  in  the 
General  Keaical  Section  prior  to  seeing  the  Chest  Clinic  doc- 
tor.    Any  veteran,   however,   can  be  seen  without  an  appointment 
if  there  is  a  question  of  hospitalization,   or  he  can  be  seen 
directly  by  the  Chest  Clinic  doctor  in  an  emere^ency . 

Upon  completion  of  the  initial  medical  examination  by 
the  Chest  Clinic  doctor,   the  veteran  is  referred  to  the  clinic 
nurse  for  instruction  in  health  care  and  precaut  ioxiary  methods 
to  safeguard  others  from  infection.     Instruction  in  the  ser- 
vices of  the  local  public  health  department  is  also  given  by 
the  nurse,   especially  in  the  case  of  a  non-service  connected 
veteran.     In  cases  where  a  referral  for  hospitalization  is 
made,   the  doctor  initiates  the  filing  of  the  ?  10  Hospitaliza- 
tion   Application,     iis  there  is  one  hundred  per  cent  referral 
of  all  tuberculous  veterans  requiring  hospitalization,  this- 
P  10  Application  is  given  to  the  Chest  Clinic  social  worker. 
This  is  an  effective  means  of  provldine   the  social  worker  with 

the  diagnosis,   the  rec*oiTimand«  tl  r»n a    an'"  r^  +  ^on                     a  ~.-e>  , 

mation,   saving  the  doctor's  time  during  a  busy  cliivic.  The 

i 
1 

1 

doctor  is,  however,  always  available  for  further  consultation 
should  this  be  advisable.     The  clerks  also  kee^  a  file  on  each 
veteraxi,  and  if  any  veteran  fails  to  keep  an  appointment  or 
follow  through  on  medical  recommendations,   the  situation  is 
then  referred  to  the  social  worker  for  follow-up. 

In  the  pre-hospital  phase,   the  social  worker  is  responsi- i 
ble  for  contacting  the  Hospitalization  Unit,  a  clearing  center 
for  all  types  of  Veterans  Administration  hospitalizations, 
while  the  veteran  is  still  in  the  clinic.     In  this  respect, 
all  veterans  are  referred  to  Veterans  Administration  hospitals. 
The  purpose  of  the  social  worker's  handlina  this  aspect  would 
seem  to  be  that  of  enabling  her  to  estimate  the  length  of 
time  she  would  have  in  helping  the  veteran  make  realistic 
planning  for  hospitalization. 

If  there  are  no  available  hospital  beds  in  Veterans  ad- 
ministrbtt  ion  hospitals,   tuber cuJous  veterans  are  usually  re- 
ferred to  the  public  health  department  for  hospitalization. 
In  general,   the  non-service  connected  veteran  makes  more  use 
of  public  hospitals  than  the  service  connected,  who  has  a  pri- 
ority on  any  Veterans  Administration  hospital  waitinv  list. 
For  the  social  worker,  referral  to  a  public  hospital  necessi- 
tates contact  with  the  local  public  health  department. 

The  social  worker  is  also  responsiole  for  referring 
veterans  who  are  non-service  connected  to  the  Contact  Division 
of  the  Veterans  Administration  to  file  a  claim  for  service 


( 


13 

i| 

i' 

connected  tuberculosis.     In  the  Veterans  Administration  every 
veteran  who  contracts  an  illness  or  disability  which  might 
have  been  a  result  of  service  in  the  armed  forces  has  the 
right  to  file  a  claim  for  monetary  benefits.     If  adjudicated 
under  the  rules  and  regulations  of  the  Veterans  Administration 
in  favor  of  the  veteran,  his  illness  is  termed  "service  con- 
nected" and  he  is  eligible  for  financial  benefits  from  the  || 
Veterans  Administration.     The  actual  amount  of  the  pension 
is  dependent  on  the  desree  of  disability. 

In  situations  where  the  veteran  cannot  provide  his  own 
transportation  to  the  Veterans  iidministrat ion  hospital,  the 
social  worker  assists  him  by  securin(<  help  from  the  Transpor- 
tation Division. 

tTnen  the  veteran  is  actually  admitted  to  the  Veterans 
Administration  hospital,   social  service  activity  in  the  Boston  ' 
Regional  Office  continues.     The  pre-hospital  planninr-  social 
worker  is  responsible  for  sending  case  summaries  of  aer 
activity  on  to  the  hospital  social  worker  thus  establishing 
a  liaison  between  the  hospital  and  the  Boston  Regional  Office 
insuring  conti.iued  casework  service, 

Hospitalizbtt  ion  Phase 

During  the  yec^r  1951  several  sections  of  the  Rutland 
Heights  Veteiu^.s  .^.a.;.  i.:.^  strat  ion  iioscital  vv=ii  e  uaoci^oiixg  a 
transition  period.     The  social  ssrvlce  dspartment  was  one  of 

{ 

these:     Therefore,   in  some  instcs-nces,   veterans  were  seen  on 


admission  by  the  social  worker  and.   In  other  instances,   they  'I 
were  seen  after  being  moved  from  the.  admission  wards.     Some  . 
were  not  seen  unless  they  were  referred  specifically  to  social jj 
service  and  others  v/ere  not  seen  unless  they  req.uestea  social  :^ 
service  help.     »^ith  two  social  v/orkers  for  a  five-hundred-bed 
hospital,   it  is  easy  to  see  how  difficult  it  would  be  for 
every  veteran  to  be  seen  routinely  by  social  service.  Social 
service  was  available  to  all  veterans  with  social,  emotional, 
or  financial  problems. 

The  social  worker  was  ToartlciOarly  useful  in  giving  as 
much  interpretation  as  pos3io.a.c  coaccr j-u^,,  che  medical  treat- 
ment  offered  at  the  hospital,  accordint^  to  individual  need. 

Burint-  this  phase  the  social  worker  in  the  Boston  Recion- 
al  Cfflce  is  also  active  by  working  cooperatively  with  the 
hospital  social  worker  in  the  following  manner:     by  giving 
assistance  with  fanily  difficulties,   by  interpreting  the 
patient's  illness  ux-o^ress  and  future  plans,  and  by  attempt- 
ing to  alter  home  conditions  which  have  or  will  have  a  defi- 
nite effect  upon  the  patient's  ultimate  recovery  or  adjust- 
ment.    The  social  worker  is  also  active  in  discharge  planning 
by  working  with  the  families  of  veterans  in  whatever  area 
needs  arise  in  relation  to  the  veteran's  return  home  and  total 
adjustment. 

8  Veterans  Administration  Hospital,   Int er-Stat Ion 
Seminar,  Rutland  Heights,  1950. 


Post-Hospital  Phase 

As  recorcie5   I  n  the  .  revious  pa^^e  the  Boston  Regional 
Office  social  viov^qi-  ^la.ya  an  active  part  in  discharge  plans 
also.     The  main  work  done  with  the  patient  himself  is  carried 
on  hy  the  hospital  social  .  ,  .,y  ..elpinu 

hlLi  to  worK  through  his  foeiin^s  aoout  leaving  the  hospital 
for  the  outside  world  from  which  he  has  been  sheltered  for  a 
long  period.     oometinies  it  may  mean  help  in  planning  for  the 
veteran's  future,  iiiaking  plans  for  follow-up  medical  treatment, 
and  referral  to  the  Boston  Regional  Office.     In  the  Boston 
Regional  Office  the  followi       procedure  is  undertaken:  super- 
vision of  discharged  cases  uutll  adjustment  is  accomplished 
and  further  supervision  and  casework  services  are  no  longer 
needed,   sending  reports  back  to  L..<=  cxut.^.,  1  l...^  ou  the  progress 
ard  condition  of  the  veteran,  and  sending  closing  summaries 
to  the  hospital  when  cases  are  closed. 

In  the  main,   this  study  is  concei         /j^ici  il.c^  pre-hospi- 
tal  planning  stage  as  the  tuberculous  veteran-patient  faces 
long-term  treatment  through  hospitalizat ioi^ .     The  social  work- 
er at  the  time  of  diagnosis  functions  ^rl.uc.rilj  as  a  facili- 
tator of  medical  treatment  by  planning  with  the  veteran  who 
has  tuberculosis  on  a  social,   erjotlonal,  and  economic  level 
in  order  to  help  him  accept  treatment  with  as  few  qualms  as  is 
possible.     In  the  three  phases  of  treatment  designated  in  this 
study,   the  tuberculous  veteran  has  as  complete  care  as  is  pos-'' 


sible  anywhere  under  the  Veterans  Administration. 


17 

CHAPTER  III 

SOCIAL  AND  EkCTIOXAL  li-iPIIC^TICKS  OF  TUBERCULOSIS 
Ii-  order  to  form  a  basis  for  the  understanding  of  the 
pH  -ht  of  any  tuberculous  patient,  one  must  have  a  sound  knowl-'' 
eai^c  of  the  niedical  aspects  of  the  illness  itself.     Otherv;ise,  ,j 
many  unnecessary  and  harmful  errors  can  be  made.     Cynthia  Rice 
^^flthan  has  bron' ht  this  ont  r  otertly  in  her  article,  "Clinic 
CaseworK  in  a  x-,asb  Tuoei  culosi c=  Survey,"  as  she  cites  the  fol- 
lowing incident: 

An  excellent  social  worker  who  was  not  equipped  | 
with  this  knowleige  failed  to  realize  that  a  patient 
whose  pul'.nonary  condition  v^^as  complicated  by  a  tuber- 
culous infection  of  the  larynx  should  not  have  been 
required  to  give  verbal  responses  in  the  social  ser- 
vice interview  si.ice  absolute  silence  is  part  of  the 
treatment  e?Fie;"'tial  to  recovery, ^ 

lucerculosis  and  Treatuient 

KiThat  is  tuberculosis?     It  is  an  infectious,   chronic  dis- 

sase,   spread  by  a     ?r",   the  tubercule  bacillus,  by  contact 

with  an  active  or  infectious  person.^    Or  again,   "it  is  largelyu 

a  chronic,   recurring,  multi-system  involving  disease. The  j 

most  co'iiiTion  ;iiode  of  transmitting  the  tubercule  bacillus  is 

through  droplet  infection  by  inhalation.^    Tuberculosis  is  not  | 

inheritable,   complete  immunity  is  never  developed,  and  there 

1  Kathan,   0£.   cit      23.  | 

2  Henry  ^  .  ial-.st ,     c  t       ^"'  -^    niedica.1     -■■ti  i     on  tuber-  \ 
culosis,   1951'  I 

3  Inter-Station  Semi  lar,  o_..  ci t .  j 

4  3akst,   G^.   cit.  ' 

I 
j 

i 


is  always  the  possibility  of  re-infection.     There  are  certain 
intrinsic  and  extrinsic  factors  that  £ive  rise  to  suscepti- 
bility to  tuberculosis,   such  as  the  effects  of  alcoholisiu  and 
pregnancy  on  the  body  system,  defects  in  metabolism,  respira-  j| 
tory  situations,  poor  social  environment  v/ith  corresponding 
inadequate  nutrition,  crowded  housing,  and  financial  distress. 
Infection  spreads  within  the  body  by  contiguity,  through  the 
blood  stream,  and  by  lymphatic  drainage. 5    Some  of  the  more 
common  symptoms  of  this  disease  are  fatigue,  loss  of  appetite, 
depression,  rapid  pulse,   "night  sweats,"  weight  loss,  cough, 
pain  in  chest,  and  hemoptysis. 

Complete  bed  rest  is  still  today  the  main  form  of  treat- 
ment for  this  disease.     Sometimes,  if  discovered  early,  a  few 
months  bed  rest  is  sufficient,  but  longer  periods  of  time 
stretching  to  one,  two,  or  three  years  are  more  prevalent. 
"Bed  rest  promotes  drainage,  eliminating  some  of  the  destroyed 
tissues  by  a  mechanical  pumping  action  which  aids  in  the  elim- 
Ination  of  mucous.""    The  lung  has  less  work  to  do  in  breathing 
and  is  given  a  chance  to  heal  during  bed  rest.    Various  forms 
of  chest  surgery  are  sometimes,  not  always,  necessary.  These 
might  involve  paralysis  of  the  phrenic  nerve  which  controls 
the  movement  of  the  diaphragm  and  gives  the  lungs  a  chance  to 
rest.    Another  way  of  resting  the  lungs  is  by  pneumothorax  ^ 

5  Charles  P.  Emerson  and  Jane  E.  Taylor,  Essentials 
of  Medicine,  p.  170. 

6  Inter-Station  Seminar,  o^.  clt . 


in  which  air  is  introduced  into  the  lung  to  form  a  cushion 
around  it.*^    In  other  cases  removal  of  the  ribs  over  the  dis- 
eased area  is  required  and  sometimes  removal  of  parts  of  the 
lung  itself. 

There  are  five  factors  necessary  toward  the  care  and  pre- 
vention of  tuberculosis  cited  by  Francis  Uphara  which  "include 
early  diagnosis,  protection  of  contacts,   long  time  institu- 
tional treatment,  after  care,  and  prevention  of  relapse.^ 

The  early  detection  of  this  disease  is  difficult  because 
there  are  usually  no  pains  to  announce  its  presence  and  often 
the  symptoms  can  be  mistaken  by  the  average  person  for  other 
illnesses.     In  1943  tuberculosis  was  rated  as  the  seventh 
cause  of  death  in  the  United  States. ^ 

As  a  recognized  public  health  problem,  the  main  modern- 
means  of  detecting  tuberculous  persons  is  by  public  health 
education,  mass  X-ray  services,  testing  of  sputum  for  tuber- 
cule  bacilli,  the  tuberculin  test,  and  by  inoculating  guinea 
pigs  with  the  suspected  tuberculous  material. 

Emotional  Shock  of  Diagnosis 

"There  are  no  two  patisnts  in  which  pulmonary  tuberculo- 
sis develops  in  the  same  way.     Likewise  there  are  no  two 

7  National  Tuberculosis  Association,  Chest  Surgery  in 
T.B.,  1951. 

8  Frances  Upham,  A  Dynamic  Approach  to  Illness — A 
Social  ^ork  Guide,  p.  104. 

9  Ibid.,  p.  124. 


patients  who  respond  in  the  same  way  to  cure."-*-      nflth  modern 
education  has  come  increased  understanding  of  human  behavior 
and  of  the  individuality  of  each  human  being.     what  tubercu-  ' 
lous  patients  have  in  common  is  tuberculosis  in  some  form. 
Kow  they  react  to  having  this  illness  is  something  that  can  be 
ascertained  only  by  knowing  each  individual,  for  each  person 
has  his  own  pattern  of  response  to  situations.    A  common  basis 
on  which  to  help  these  patients  face  their  future  in  a  realis- 
tic way  is  to  recognize  the  presence  of  an  emotional  shock  at 
the  time  of  diagnosis,  allowing  the  patient  the  opportunity  to 
express  at  that  time  what  his  illness  means  to  him.     It  may 
mean  the  interruption  of  a  business  career,   schooling,  support 
of  a  family,  or  it  may  be  a  blow  to  his  ego. 

The  patient  reacts  to  the  diagnosis  of  tuber- 
culosis with  his  emotions,  his  intelligence  and  his 
degree  of  susceptibility;  that  is,  with  his  person- 
ality, which  is  the  sum  total  of  his  experiences  in 
life,  his  equipment  for  living,  and  therefore,  for 
meeting  the  emotional  crisis  precipitated  into  his 
existence  by  tuberculosis  and  the  demands  of  its 
treatment.    As  personalities  vary  so  individual 
reactions  to  disease  vary.^^ 

To  deal  with  the  patient's  emotional  shock  at  the  time  of 

diagnosis  is  to  help  lessen  his  fears,  enabling  him  to  move 

ahead  toward  beneficial  treatment.     The  person  who  discovers 

10  Edward  W.  Hayes,   "The  Procedure  which  makes  Possible 
the  Adjustment  to  the  Cure  of  the  Patient  with  Pulmonary  Tuber- 
culosis and  the  Technique  for  Carrying  Cut  these  Procedures," 
Diseases  of  the  Chest,   16:379,  October,  195C. 

11  Everett  F.  Conlogue,   "i-.eatal  and  Nervous  jrhcnomena 
in  Tuberculosis,"  American  Review  of  Tuberculosis.  42:162, 
August,  19A0. 


1 


I, 

21 

ij 

that  he  has  tuberculosis  also  discovers  that  he  probably  has 

a  well-formed  set  of  crystallized  attitudes  which  have  developejl 

from  his  understanding  and  acceptance  of  the  implications  of 

his  disease,  from  his  fears,  misinformation,   or  from  social 

pressures.     In  most  cases  these  attitudes  are  a  haxidicap.  :j 

Unless  he  is  given  an  opportunity  to  express 
and  to  work  through  his  fears  and  anxieties,  ten- 
sions will  be  stored  up  to  generate  future  diffi- 
culties.    The  flame  that  bursts  out  into  irregu- 
lar discharge  is  often  kindled  at  the  time  diagno- 
sis is  revealed. -^2 

'iffh3,t  Dr.  Everett  F.  Conlogue  calls  " tuberculophobla, "  and  the 
patient's  preconceived  idea  of  tuberculosis  sometimes  stems  | 
from  association  with  the  aged  concepts  of  the  "white  plague"-^^ 
Patients  sometimes  experience  a  fear  of  stigma,  fear  of  separa- 
tion and  aloneness,  fear  of  being  failures,  fear  of  death  and 
surgery,   in  addition  to  fear  of  the  destructiveness  of  the 
illness  itself.     At  the  time  of  diagnosis  it  is  an  important 
task  for  the  social  worker  to  clarify  with  the  patient  what  he 
has  already  been  told  about  tuberculosis,   to  gain  his  confi- 
dence and  cooperation  in  order  to  facilita.te  the  medical  recom-|| 
mendations  and  to  prevent,   in  some  measure,  any  future  mani- 
festations of  neurotic  behavior.  | 
Previous  personality  plays  a  definite  part  in  the  type  of  , 

reaction  an    individual  rnakes     to    the     diagnosis  of  illness.-^^ 

12  Tollen,   0£.  cit . ,  p.  28. 

13  Conlogue,  o^.   cit.,  p.  162.  ' 

14  Alfred  0.  Ludwig,   "Emotional  Factors  in  Tuberculo- 
sis," Massachusetts  Society  for  Mental  Hygiene,  June,  194?. 


I 


! 

|.  22 


A  patient  'nay  respond  to  his  illness  as  a  welcomed  escape  from 

a  streso^.^  uo.;,.  situation,   or  a  coiiscient ious  person  might 

put  off  treatment  feeling  he  cannot  be  spared  froQi  the  care  of 

his  fe.'^^llj.     In  many  cases  fear  and  depression  follow  the 

initic.-:-     ia^^nosis  of  tuberculosis.     The  eniotional  shock  of  the 

diagnosis  is  not  a  uniform  one  which  can  be  handled  according 

to  a  set  of  rules,  because  the  underlying  emotional  reaction 

has  been  develop!, sli.ce  oar  CLiildhood. 

The  patient's  ability  to  withstand  this  strain 
depi;nds  upon  the  character  of  his  personality  in  the 
past,   the  support  he  receives  in  the  present  circum- 
stances, and  his  capacities  for  the  future. ^5  || 

ii  state'nent  ^ade  in  connection  with  helpins.  tuberculous  oatienta' 

face  sur-^ety  caa  well  ^e  a^->xi-c:d  to  he  1    '  -      thoui        tue  ti.i.e 

of  diagnosis.  i[ 

i 

Whether  he  wants  or  can  use  such  a  service  is  ' 
a  decision  which  each  patient  must  make  for  himself. 
He  must  decide  whether  he  can  take  advantage  of  the 
medical  service  available  to  him.     The  sociaJ  worker's 
contribution,  through  his  relationship  to  the  patient 
and  the  doctor,   is  often  a  major  factor  In  that  decision 
and  therefore  an  indispensable  ing;redient  in  the 
patient's  maximum  use  of  the  facilities  the  community 
has  provided  for  his  cure.^^ 

Tuberculosis  and  Personality 

The  persor^^  ■ ty  of  the  tuberculous  _    t    ^   t   is  an  extremely 

importai^t  factor  to  Li  dealt  with  in  the  process  of  medical 

treatment  as  it  can  be  the  controlling  tool  for  improvement 


15  bnitad  Stc^tcS  rublic  Health  Seivice,  >-8-.lcal  poclal 
Service  in  Tuberculosis  Control,  k'l  see]  laaeous  Publicist  ion, 
34,  1946. 

16  Ophelia  3.  sL^YPt,   "rielp^ng  a  Tuberculous  Patient  To 
Face  Surgery,"  Journal  or  Social  Gasewor-A,  iviarch  1951. 


or  relapse,    as  in  laany  chronic  diseases  where  the  patient  has 

time  to  think  during  long  periods  of  treatnient,   often  his 

thoughts  are  turned  inward.    Many  authorities  have  spoken  of 

the  tuberculous  patiexit  as  being  self -centered.     But,  when  a 

patient  i s  on  complete  bed  rest  and  must  constantly  be  on  guarc . 

against  exertion  of  any  kind,  no  matter  how  minute,   it  would. 

seem  that  there  is  inherent  in  the  disease  itself  and  the 

hospital  setting  the  tendency  to  increase  the  focus  on  one's 

self.     There  is  still  much  dispute  as  to  whether  or  not  there 

is  a  certain  personality  type  predisposed  to  tuberculosis. 

From  the  time  of  Hippocrates,   2, COO  years  ago 
there  has  been  determined  effort  to  sste.bllsh  a  con-  i 
stitutional  or  inherited  type  definitely  disposed  to 
tuberculosis.     However,  as  regards  the  factors  of  the 
mind  and  emotions,   the  poor  mental  hygiene  accompany- 
ing poor  social  and  economic  conditions,  especially 
when  augmented  by  the  strain  of  adolescence,  the 
worries,   the  sorrows  of  humanity,  are  among  the  fac- 
tors of  the  environment  most  potent  in  presenting 
opportunities  for  infection  and  shaping  its  course.-^'' 

Persons  who  have  always  been  very  independent  find  it 
difficult  to  look  to  others  for  the  gratification  of  even  their 
simplest  need,  as  is  so  often  the  case  with  the  hospitalized 
patient.     These  are  usually  the  persons  in  the  pre-hospital 
planning  period  who  seem  quite  capable  of  handling  their  own 
affairs,   but,  who,   once  hospitalized,   have  a  difficult  time 
adjusting  to  hospital  routine.     In  a  like  manner,  persons  who 
are  very  dependent  may  adjust  very  well  to  hospital  life  but 
find  it  difficult  to  be  discharged  and  make  their  way  in  the 
17  Conlogue,  o£.  cit . ,  p.  170 


outside  world  again.  These  persons  seem  able  to  take  advantage! 
of  social  service  help  in  the  pre-hospital  planning  period. 

Individuals  with  a  history  of  anti-social,  psychopathic, 
or  alcoholic  behavior,  for  example,  are  difficult  to  work  with  | 
because  of  their  personality  patterxis,  and  usually  these 
patients  are  not  able  to  complete  hospital  treatment.  Some- 
times they  are  difficult  to  spot  in  the  pre-hospital  period,  , 
and,   if  recognized,   the  pressure  of  time  and  their  long-term 
personality  maladjustments  are  against  the  social  worker's 
ability  to  help  these  people. 

In  a  study  of  the  personalities  of  sixteen  hospitalized 
tuberculous  patients  in  1948,  the  consensus  was  that  no  pre- 
tuberculosis  personality  factors  common  to  all  patients  were 
discovered,  or  even  factors  common  to  a  large  majority  of  them 
in  regard  to  either  general  structure  or  specific  conflict 
situations;  the  one  exception  was  dependency  conflicts  or 
relatively  uninhibited  dependency  strivings.^® 

Socio-Economlc  Factors 

Economic  problems  are  often  a  main  concern  among  tubercu- 
lous patients  and  their  dependents.     Too  often  the  breadwinner 
of  a  family  is  stricken  with  this  disease.     The  long-term 
hospital  care  presents  a  heavy  financial  burden  for  the  fami- 
lies of  patients  and  frequently  leads  to  more  serious  marital  ' 

18  John  D.  Benjamin  and  others,   "a  otudy  of  the  Person- 
ality in  Pulmonary  Tuberculosis,"  American  Journal  of  Ortho- 
psychiatry, 38:706,.  October,  1948. 


25 


or  family  difficulties. 

Although  tuberculosis  strikes  at  persons  of  all  economic 
levels,  the  majority  of  tuberculous  patients  come  from  low 
economic  £roups  where  the  inadequate  standard  of  living  can 
be  counted  as  a  factor  in  lowering;  resistance  to  this  infec- 


tious  disease,    as  previously  mentioned,  poor  nutrition  and 
crowded  living  conditions  also  contribute  to  an  individual's 
susceptibility . 

Not  only  the  person  with  dependents  has  financial  worries 
but  also  the  single  person  without  any  assistance  from  friends 
or  relatives.     Should  there  be  a  hospital  waiting  list,   it  is 
almost  impossible,  in  many  instances,  for  these  single  men  to  ' 
follow  medical  recommendations  when  they  are  dependent  on  them- 
selves for  support.    However,  in  comparison  to  persons  with 
other  chronic  illnesses,  the  tuberculous  patient  is  fortunate 
in  being  able  to  secure  long-term  medical  care  without  direct 
responsibility  for  payment.    However,  when  patients  come  from 
a  low  economic  group,  the  financial  problem  seems  to  be  part 
of  a  vicious  circle.     This  seems  to  be  true  in  those  instances 
where  the  patient  must  go  back  to  the  same  low  standards  of 
living  where  the  possibilities  of  relapse  are  quite  probable. 

Pulmonary  tuberculosis  takes  its  heaviest  toll  of  patients 
from  the  young  adult  age  groups,  attacking  mainly  persons  from 
fifteen  to  forty-five  years  of  age.     This  illness  is  more  pre- 
dominant in  males  than  females.    It  causes  more  deaths  in  the 

1- 

I 


I 


socially  productive  a^e  groups  than  in  any  other  disease. 
This  fact  is  si£nificant  as  it  points  out  the  loss  of  healthy 
citizens  to  our  nation,  and  it  reflects  the  extent  of  the  eco- 
nomic drain  on  public  funds. 

As  tuberculosis  affects  mainly  those  persons    in  the 
socially  productive  age  group,  it  is  important  to  consider  the 
effects  on  the  individual  of  interruption  of  vocational  plan- 
ning and  employment,     iihen  a  person  has  struggled  through 
higher  education  and  is  about  to  embark  on  a  promising  career, 
any  years  taken  out  of  his  life  for  treatment  of  illness  would 
be  a  source  of  frustration  and  depression.     The  person  already 
employed  has  to  face  the  loss  of  security  in  relation  to  a 
permanent  Job  and  regular  income.     The  type  of  Job  that  the 
unskilled  worker  has  may  have  been  instrumental  in  bringing 
about  his  illness.     The  death  rate  for  unskilled  workers  with 
tuberculosis  is  twice  that  for  skilled,  three  times  that  for 
clerks,  and  six  times  that  for  professional  people. 20  xhe 
disability  that  may  occur  from  this  illness  may  mean  that  a 
change  in  plans  for  education  or  in  occupation  is  necessary. 

Effect  on  the  Family 

The  loss  of  a  main  family  figure  to  hospitalization  often 
creates  new  family  problems  and  results  in  a  change  of  family 
roles  when  a  long  period  of  separation  is  involved.     Often  the 

19  Upham,  o£.  cit.,  p.  61. 

20  Ibid,,  p.  64. 


I 

i 


wife  has  to  take  over  the  "man's  Job"  of  supporting  the  family 
and  other  duties  normally  appropriated  by  the  husband.    In  our 
modern  society,  where  culture  determines  that  a  man  must  be 
the  strong  cornerstone  of  his  family,  any  lonp;  illness  will 
create  feelings  of  inadequacy  and  loss  of  status,  not  only  in 
the  family,  but  in  the  community.     The  attitudes  of  the  family  || 
toward  a  patient  affect  his  ability  to  accept  realistically 
this  interruption  in  his  life.     The  family  should  be  educated 
to  an  understanding  of  the  patient  and  his  illness  in  order  to 
insure  cooperation  in  the  treatment  process.     For  example,  || 
in  the  family  which  is  ignorant  of  tuberculosis,   the  fear  of 
infection  may  heighten  the  patient's  own  anxiety  and  may  im- 
pose ostracism  upon  him,  making  him  withdraw  more  into  him- 
self. 

Often  the  family  needs  more  care  than  the 
patient  from  the  emotional  point  of  view.  They 
too  must  learn  to  accept  the  disease  and  must  be 
urged  to  treat  the  patient  as  objectively  and 
normally  as  possible. 2^ 

The  keaninc  of  Hospitalization 

Pepper's  remark,   "Fear  is  every  doctor's  enemy 
and  every  patient's  bed-fellow"  may  be  applied  to 
the  tuberculous  with  particular  aptness.     When  they 
enter  a  hospital,  patients  do  not  leave  their  ten- 
sions and  anxieties  behind.     These  go  with  them, 
rthile  the  body  rests  emotional  and  psychic  energy 
accumulate . 22 

The  patient  who  is  awaiting  hospitalization  can  conjure  up 


21  Ludwig,   o£.   cl t . 


many  fears  and  anxieties  about  tirie  tiospital.     In  addition,  new 
tensions  and  anxieties  are  created  by  the  need  to  adjust  to  a 
totally  different  environment.     Separation  from  family  and 
friends  increases  the  patient's  fear  of  being  forgotten  and 
alone.     The  fact  that  a  patient  must  be  segregated  from  others 
because  of  the  possibility  of  infecting  others  may  give  rise  tc) 
feelings  of  unworthiness.    Ke  may  worry  about  his  family  and 
life  on  the  outside  of  the  hospital.     On  the  other  hand,  depend^ 
ing  on  his  personality,   the  fact  that  his  family  can  and  does 
manage  without  him  m.ay  increase  his  feelings  of  not  being  need^. 
The  longer  the  period  of  separation,  the  more  acute  the  feeling 
of  loss  of  status  and  insecurity. 

Again,  the  personality  of  the  patient  is  a  crucial  area  iij 
the  realistic  acceptance  of  his  illness  and  attitudes  toward 
treatment.    A  very  passive  patient  may  give  in  to  fate  and 
lose  any  motivation  to  get  well,  perhaps  unconsciously  having 
his  dependency  needs  fed.    A  person  with  paranoid  tendencies 
may  feel  acutely  the  isolation  from  the  outside  world,  a  stigm^ 
and  project  his  suspicions  on  to  others  within  the  hospital. 
Hospitalization  may  revive  previous  unha^.-.y  experiences  of 
abandonement  or,   in  those  with  guilt  feelings,  punishment. 
The  very  inactivity  that  hospitalization  imposes  on  patients 
contributes  to  the  inability  of  some  patients  to  adjust  to 
hospital  treatment  and  routine. 


CHAPTER  IV 
FROBLSI-:S  TN  PRE-HOSFITaL  PLANNING 
This  cua^>toi-  is  dlvL^ed  esseiit ially  into  two  sectloas. 
The  first  part  is  a  presentation  of  eight  case  aurnmaries  in 
order  to  view  more  clearly  the  variety  of  rr-oVJems  that  arise 
during  the  ore-hospital  planning?  period,    ^-lother  ^^urpose  in 
presentinsf  the  case  sumiiaries  is  to  show  how  the  handling  of 
these  cases  affect  hospital  adjustment  and  hospital  dischar£;e. 
The  second  part  is  concerned  with  categorizing  the  problems 
to  give  an  over-all  picture  of  the  numbers  of  veterans  needing 
social  service  help  in  specific  areas. 

It  should  be  kept  in  liiina  tnat  in  the  pre-hospital  plan- 
ning period,   in  the  majority  of  cases,   there  ws.s  only  one  con- 
tact with  social  service. 
Case  A. 

hir.  A.,  a  31  year  old,  married,  >forld  War  II 
Veteran,  mechanic's  attendant,  was  referred  for  emer- 
gency hospitalization.     Diagnosis:     tuberculosis,  pul- 
monary,  chronic,  far  advanced,  active. 

He  lived  in  his  own  home  with  his  wife  and  three 
small  children,  a  fourth  child  hospitalized  for  tu- 
berculosis of  the  bone.     Both  the  veteran  and  his  wife 
were  employed  ^n-'  rented  one  apartment  in  their  home. 

Diagnosis  did  not  com.e  as  a  complete  shock  since 
he  had  suspected  illness  for  a  long  time  although  he 
had  not  done  anything  about  it  before.     The  fact  that 
he  had  waited  so  long  before  seeking  medical  attention 
seemed  to  indicate  that  it  took  him  some  time  to  work 
through  his  own  feelings,  and  that  now  he  had  accepted 
his  illne.ss  and  the  need  for  hospitalization  with  a 
mature  attitude  and  a  realistic  outlook.     He  was  able 
to  verbalize  freely  and  to  participate  easily  in  the 
interview.     His  only  real  expressed  anxiety  was  cen- 


tered  around  the  support  of  his  faraily  which  was 
not  too  realistic  since  their  income  was  above  that 
of  any  arency  that  could  help  him.     Perhaps  his  anxiety 
was  more  indicative  of  inner  tension,  but  tension  which 
he  was  able  to  control  by  projection. 

During  hospitalization  he  made  use  of  social  ser- 
vice only  to  the  degree  of  making  inctuiry  as  to  his 
family's  economic  situation  and  of  his  filing,  for  a 
disability  claim.     He  remained  in  the  hospital  ten 
months  and  was  discharged  with  maximum  hospital  bene- 
fit. 

This  case  illustrates  a  limited  type  of  service  rendered 
by  the  social  worker  in  the  ore-hospital  planning  period  cen- 
tered mainly  around  financial  matters.     The  important  thing 
to  note  in  this  case  is  not  the  actual  referral  for  financial 
assistance,  because  the  veteran  did  not  really  need  it,  but 
the  use  the  social  worker  made  of  his  request  to  give  him  sup- 
port and  encouragement  in  carrying  through  medical  recommenda- 
tions.    It  seems  clear  that  Mr.  A.'s  real  anxiety  was  focused 
on  his  own  fears  of  his  illness.     The  social  worker  did  not 
point  this  out  to  him  but  built  on  his  positive  attitudes  and 
thus  strengthened  his  ability  to  go  ahead  with  medical  recom- 
mendations. 
Case  B. 

Mr.  B.,  a  43  year  old,   single,   iVorld  itfar  II 
Veteran,  unemployed  restaurant  worker,   was  referred 
for  hospitalization.     Diagnoses:     tuberculosis,  pul- 
monary, moderately  advanced  active;  lung  condition. 

He  lived  in  a  single  room,  had  no  relatives,  was 
employed  intermittenly ,  often  receiving  public  finan- 
cial aid. 


During  the  pre-hospital  planning  interview,  it 
was  noted  that  Mr.  B.  perspired  profusely  though  he 


appeared  calm  in  his  attitude  and  was  generally  agree- 
able and  pleasant.     He  accepted  the  need  for  hospitali- 
zation with  realistic  understanding  and  displayed  intel- 
ligence ree:ardin£  his  illness.     He  saw  as  his  only  need 
from  social  service  financial  assistance  pending  hospi- 
talization. 

JXiring  hospitalization  he  made  an  adequate  adjust- 
ment and  was  cooperative  in  treatment.     It  was  during 
the  sixth  month  that  he  seemed  to  become  extremely  ner- 
vous, threatening  to  leave.     In  recognition  of  this,  he 
was  given  a  pass,   returned  to  the  hospita].,  and  left 
again  against  medical  advice.    His  excuse  was  that  he 
disliked  hospitals  in  general  and  had  to  get  away. 

This  case  illustrates  the  difficulty  incurred,  during  the 
pre-hospital  period  in  particular,  when  faced  with  a  rather 
long-term  problem  of  maladjustment.     His  case  history  indicatec. 
an  inability  to  settle  down  to  one  place  for  very  lon^,  irra- 
tic  employment,  and  a  tendency  toward  instability.     The  ^les- 
sure  of  time  limits  the  interpretation  and  understanding  that 
can  be  given  to  such  patients.    Also,  Mr.  B.  did  not  feel  he  | 
was  in  need  of  help  with  other  than  concrete  things.     He  made 
no  use  of  social  service  during  the  period  when  he  was  so  ner- 
vous, and  his  attitude  communicated  a  definite  resistance  to 
any  offer  of  help.     Drifters,  as  was  ..r.  5.,   have  a  difficult 
time  adjusting  for  long  periods  to  hospitalization  and,  as  in 
Mr.  B.'s  case,  present  a  real  problem  to  medical  treatm.ent. 
Case  C. 

kr.  C,  a  35  year  old,  married,  tforld  Jar  II 
Veteran,   carpenter  by  trade,  was  referred  for  emer- 
gency hospitalization  on  a  social  basis.  Diagnoses; 
tuberculosis,  pulmonary,   chronic,  minimal,  active; 
arthritis  of  the  spine. 

Kr.  C.  lived  with  his  wife  and  three  children 


in  very  crowded  quarters  necessitating  one  child's 
sleeping  with  the  parents.     He  had  been  unemployed 
for  some  time  because  of  his  arthritic  condition, 
and  in  order  to  supplement  his  income,  l^r.  C.'s  wife 
worked  nights.     During  a  routine  chest  X-ray  at  the 
Boston  Regional  Office  iirthritic  Clinic,  a  shadow  on 
his  lungs  was  discovered  and  he  was  referred  to  the 
Chest  Clinic. 

This  added  illness  came  as  a  real  shock  to  Kr. 
C.  who  had  been  asymptomatic,  and  he  cried  several 
times  during  the  initial  pre-hospital  interview. 
Fear  of  tuberculosis  and  long-term  hospitalization 
resulting  in  separation  from  his  family,  fear  of  hav- 
ing infected  his  family,  fear  of  the  unknown  future, 
and  anxiety  around  the  financial  status  of  his  family 
were  all  present  and  handled  during  this  interview 
by  the  social  worker.     By  recognizing  his  shock  and 
fears  Ou  a  realistic  basis,   coupled  with  interpreta- 
tion,  support  and  encouragement,  Mr.  C.  was  able  to 
move  ahead  to  make  practical  plans  for  his  family.  j 
His  desire  to  get  better  was  strong,  and  his  atti-  ' 
tude  toward  his  illness  and  hospitalization  became 
realistic  and  accepting.     He  entered  the  hospital 
on  the  same  day  as  referral  with  the  assurance  that 
the  social  worker  would  watch  over  his  family. 

This  veteran  was  able  during  hospitalization  to 
make  use  of  social  service  help  for  continued  emo- 
tional support  and  as  a  means  of  reassuring  himself 
about  his  family's  welfare.     Through  the  dual  efforts  \ 
of  the  Regional  Office  and  hospital  social  workers, 
Mr,  C.  completed  treatment  and  after  one  year  of 
hospitalization  was  discharged  with  maximum  hospital 
benefit. 

It  is  important  to  note  in  this  case  that  Mr.  C.'s  anxielj/ 
and  fears  were  handled  mainly  i     the  pre-hospital  period  to 
the  extent  that  he  could  move  ahead  toward  hospitalization 
despite  the  severe  social,   emotional,  and  economic  problems 
present.     He  was  able  to  accept  his  illness  for  tt.^  u.oment  and 
could  enter  the  hospital  with  less  pressure  and  with  confidencis 


in  his  ability  to  get  well.     Coatinued  support  during  hospl- 


talization  was  necessary,  however,  because  of  Kr.  C.'s  itiitial 
shock  at  his  illness,   since  what  is  actually  entailed"  i  hos- 
pitalization does  not  become  a  reality  until  entered  into. 
His  dependent  nature  enabled  him  to  make  use  of  social  service 
and  to  adjust  to  hospital  routine.     Durlnj£  hospitalization  he 
displayed  more  and  more  an  intellii^ent  understanding^  of  his 
disease  and  an  increased  ability  to  benefit  from  treatment. 
That  personality  factors  are  extremely  important  in  completing 
treatment  is  illustrated  more  vividly  by  the  followin^i  case 
when  compared  to  this  one. 
Case  D. 

Mr.  D.,  a  28  year  old,  married,   rtorld  rfar  II  Vet- 
eran, textile  worker  by  trade,  was  referred  for  emer- 
gency hospitalization  on  a  social  basis  to  protect  two 
small  children  at  home.     Diagnosis:  tuberculosis,  pul- 
monary,  chronic,  moderately  advanced,  active. 

On  referral,  his  attitude  toward  hospitalization 
was  that  his  main  concern  was  to  become  better.     He  had 
learned  of  his  illness  two  weeks  prior  to  the  pre-hospital 
planning  interview  follov^ing  a  routine  chest  x-ray  at 
his  place  of  employment.    He  displayed  an  independent, 
mature,  and  realistic  attitude  toward  his  illness  and 
was  anxious  for  hospitalization.     He  asked  no  help  of 
social  service  since  he  had  already  applied  for  finan- 
cial assistance  for  nia  family,   filed  a  claim  for  a  serv- 
ice connected  pension,  and  contacted  the  local  health 
department  regarding  x-rays  for  his  family.     He  returned 
just  prior  to  hospitalization  to  enlist  the  social  work- 
er's aid  in  completing  his  application  for  financial 
assistance  from  a  community  agency. 

During  hospitalization  he  did  not  make  a  good  ad- 
justment.    Once  realizing  the  de.nands  which  would  be 
m.ade  upon  him,   his  mature  attitude  disappeared.     He  ex- 
pressed his  fears  regarding  illness  indirectly  by  wor- 
rying over  his  family,   their  financial  situation,  and 
his  sepixration  from  them.     Throughout  his  whole  period 


of  hospitalization  it  was  evident  that  he  wae  continu- 
ally waging:  a  battle  within  himself  centered  around  his 
basic  inability  to  accept  his  illness.    He  continually 
compared  himself  to  others  worse  off  than  himself  and, 
because  he  was  asymptomatic,   could  not  believe  that  he 
was  really  ill.    He  did  make  use  of  social  service  dur- 
ing hospitalization  but  only  as  a  means  of  assuring  him- 
self of  his  family's  welfare.    He  could  not  accept  any 
attempts  to  help  him  face  his  basic  difficulty  and  left 
the  hospital  after  thirty-seven  days  against  medical 
advice  pleadiif-  financial  difficulty  at  home. 

Essentially  this  case  illustrates  the  importance  of  hand- 
ling: "the  shock  of  diagnosis  at  the  time  it  is  luade  an;  the  im- 
portance of  personality  factors  in  making  adjustment.  This 
case  also  Illustrates  that  problems  cannot  always  be  antici- 
pated during  the  pre-hospital  planning  interview,     i-ir .  ju. ' s 
initial  mature  and  realistic  attitude  was  a  defense  mechanism 
against  his  inner  fears  of  illness.     His  competence  In  making 
his  own  pre-hospital  plans  suggested  to  the  social  worker  the 
impression  that  he  gave.     In  many  respects  this  case  illus- 
trates soine  of  the  same  social  and  financial  problems  indi- 
cated in  the  previous  case.     The  difference  to  be  noted  is  the 
way  in  which  Mr,  C.  and  Mr.  D.  handled  their  fears.    Mr.  D. 
could  not  admit  to  himself  any  weakness  and  continually  had 
to  build  up  his  own  ego  by  comparing  himself  with  others  and 
by  doing  things  independently.     He  could  not  accept  the  fact 
that  his  family  could  and  did  manage  without  him. 
Case  ■£. 

Mr.  E.,  a  53  year  old,  married,   »Vorld  rfar  I  Vet- 
eran, pipe  fitter  by  trade,  was  referred  for  hospitali- 
zation.    Diagnoses;  tuberculosis,  pulmonary,  moderately 


35 


i 

advanced,  active;  multiple  rheumatoid  arthritis. 

This  veteran  had  two  previous  Irre^^ular  dischargees 
frooi  tuberculosis  hospitals  which  he  indicated  were  be- 
cause he  became  bored  and  restless,    although  Mr.  E.  had 
a  somewhat  facetious  attitude  durinp;  the  pre-hospital 
ii.terview  toward  his  illness  because  he  didn't  consider 
it  serious  as  it  ^ave  him  no  trouble,  his  attitude  toward  ij 
hoapitalizat ion  seemed  realistic  and  practical.  He 
easily  discussed  his  previous  experiences  in  bein£  hos- 
pitalized and  had  every  intention  of  completing  treat- 
ment this  time  because  of  his  desire  to  £et  well.  He 
indicated  that  he  had  no  problems  with  which  he  would 
need  the  social  worker's  help  and,  on  the  whole,  had  a 
very  looo  ^  tt'fude  toward  complet'  ■;    ledlcal  treatment. 

During  hospitalization  Mr.  E.  was  a  difficult  pa- 
tient and  recognized  no  need  for  help  in  social  and 
health  areas.  His  main  difficulty  in  adapting  to  the 
hospital  Involved  his  habit  of  intermittent  drinking. 
After  a  year  he  left  the  hospital  against  niedical  ad- 
vice, following  a  dririklng  episode  in  which  discipli- 
nary action  was  pending. 

Alcoholism  lea  widespread  ■oroblem  an.on^.  tuberculosis 
^-c;.  t  .  e I  o ,    Lne  raaJOi^iy  of  whoiu  do  i.ot  ieco,--nize  It  as  such. 
During  the  pre-hospital  planning  period,   it  is  often  difficult 
to  detect  a  veteran  with  an  alcoholic  problem.     If  he  has  been 
«^.'-Owa  to  socijii  SqiTvice  uef ore,   it  is  -^uite  probable  that 
the  social  worker  would  be  aware  of  it.     Otherwise,  unless 
the  veteran  brings  it  u.   himself  or   shows  outws'. r:"'  s'     s  of 
inebriation,   the  social  wordier  misses  this  important  ^-roblerr  . 
In  this  case  there  was  no  indication  of  kr.  E. ' s  being  a  he&vy 
drl->er  prior  to  hospital! z-^  t  lo   .       ,  >    ?v.  h  the  hospital  hac 
an  «.lcohollcs  anonymous  ;-rou_.-,   this  vetert^n  would  L:ot  partici- 
pate in  its  activity.     Despite  his  difficulty  in  adjusting  to 
hospitallzatic  .1,  he  probably  woulc  have  been  able  to  complete 


36 


treatment  hbid  he  not  been  addicted  to  drinking.     Cn  the  other 
hand,   his  basic  difficulty  mi^ht  have  ca,riseu  in  other  ways.  ' 
Fundamentally  Mr.  E.,  did  not  accept  his  illness  emotionally 
even  though  he  had  an  intelliff-ent  understanding  of  his  illness.! 
Case  F« 

Mr.  F.,  a  33  year  old,  married,   rforld  (A^ar  II  Vet- 
eran, or^^anist,  was  referred  for  hospitalization,  di- 
agnoses: tuberculosis,  pulmonary,   chronic,   far  cidvanced, 
active;  right  thoracoplasty. 

This  veteran  lived  with  his  wife,  and  a  nine-year- 
old  daughter  was  boarded  with  in-laws  as  a  precautionary 
measure.     BotVi  the  veteran  and  his  wife  had  long  his- 
tories of  tuberculosis  and  irregular  hospital  dischar£.es. 
There  were  no  financial  problems. 

In  the  pre-hospital  planning  interview  both  the 
veteran  and  his  wife  were  visibly  and  acutely  distressed 
over  the  reactivation  and  recomuiendation  of  hospitali- 
zation.    Both  refused  any  social  service  assistance, 
the  veteran  claiming  he  "was  an  old  hand"  at  referral  ; 
and  could  handle  his  own  affairs.     The  total  interview 
lasted  not  more  than  five  minutes,   both  the  veteran  and 
his  wife  leaving-  the  office  in  a  great  hurry. 

The  veteran  remained  in  the  hospital  only  fifteen 
days,  as  could  be  expected  from  his  attitude,  and  failed 
to  return  following  a  weekend  pass.     His  discharge  di- 
agnosis Included  chronic  anxiety  state. 

This  case  illustrates  laore  sharply  than  any  other  in  this 

study  the  limitations  of  the  pre-hospital  social  worker  when 

assistance  is  refused  so  outwardly.     ¥r,  F.  exhibited  a  marked 

inability  to  adjust  to  his  illness  anu.  a  facility  in  running. 

away  from  it.     That  he  could  not  even  discuss  his  feelings 

was  indicative  of  the  r-al  ^eoth  of  his  emotional  distress 

ana  anxiety. 


37 


1 
[ 

Case  G.  I 

i-r.  '3-.,  a  42  year  ol^.,   divorced,   .vorlo  ,tui  II  Vet- 
eran,  street  cleaner,   was  referred  for  hospitalization. 
Diagnosis:  tuberculosis,  pulmonary,   chronic,   far  ad- 
vanced, active. 

This  veteran  had  one  previous  irregular  discharge 
from  a  public  sanatorium.     He  would  not  discuss  his  rea- 
sons for'  leaving  the  sanatorium  except  that  "they  were 
personal."    His  attitude  toward  the  social  worker  was 
that  of  veiled  hostility  c:ond  suspicion.     His  real  at- 
titude toward  his  illness  was  revealed  in  his  feeling  i 
that  everyone  shunned  him,   that  employers  placed  a  stig- 
ma  on  him  ana  would  not  hire  him.    Althouth  he  found  it 
difficult  to  manage  financially,  he  would  accept  no  re- 
ferral for  financial  aid.     Because  of  an  exceptionally 
Ions  hospital  waiting  list,  he  wished  to  "report  him-  ,1 
self"  to  the  health  departuient  rather  than  have  the  so- 
cial  worker  contact  the  health  department  for  him. 

Mr.  G.  did  not  enter  the  hospital  until  six  months 
later,  and  he  had  not  applied  for  hospitalization  through 
the  health  department.     He  left  against  medical  advice 
the  day  after  he  was  adritte-j  to  the  hospital. 

hr.  G.  had  many  feelin.^o  of  rejection  which  were  not  seen 
so  easily  in  other  cases  as  in  tais  one.     He  was  withdrawn  and 
could  not  rr.nke  relationships  easily.     His  feelings  regarding 
illness  and  hospitalization  were  completely  negative  and  en- 
hanced by  feelings  of  stigma  and  unworthiness  which  he  was  not 
mature  er^ough  to  handle  realistically.     He  refused  any  help, 
even  that  of  financial  aid. 
Cfc^se  H. 

Mr.  H.,  a  41  year  ol.,    ,  Lvorced,  V/orld  V/ar  II  Vet- 
eran, metal  finisher  by  trade,  was  referred  for  hospi- 
talization.    Diagnosis:  tuberculosis,   pulmonary,  chronic, 
far  advanced,  active. 

The  initial  diagnosis  of  tuberculosis  had  oeen  made 
two  weeks  prior  to  hospital  referral  by  a  private  doctor. 


The  veteran  had  _lven  up  his  jou  and  small  apca.r tment 
and  moved  in  with  a  sister  pending  hospitalization. 

He  was  quite  anxious  about  hospitalization,  rais- 
in*^ many  practical  and  intelliiieat  questions  as  to  what 
to  expect.     The  opportunity  to  discuss  his  illness  and 
his  future  hospitalization  relieved  his  anxiety  and 
helped  him  look  more  realistically  toward  medical  treat- 
ment with  fewer  fears  of  the  unknown.    He  was  referred 
for  financial  assistance  pendln^^,  hospitalization  and 
£ave  evidence  of  no  other  problems  which  would  delay 
hospitalization. 

During  hospitalization  his  attitude  toward  his  ill- 
ness was  realistic  and  his  adjustment  was  good.  During 
a  routine  interview  while  hospitalized,   he  sought  help 
in  regard  to  a  drinking  problem.     It  v;as  felt  that  be- 
cause of  good  interpretation  from  the  pre-hospital  inter 
view  he  was  able  to  develop  a  positive  attitude  toward 
hospitalization  and  was  able  to  complete  treatment. 

The  latter  case  ijlustrates  how  interpretation  at  the 
time  of  diagnosis  prepc^ratory  to  hospital  admission  can  les- 
sen fears  and  develop  a  positive  attitude  toward  hospitaliza 
tion. 

The  previous  cases  were  presented  to  show  the  various 
types  of  problems  encountered  mainly  in  the  pre-hospital 
r^^rior',   to  prese-^t  t'r~   -difficulties  of  social  service  in 
handling  certain  personality  types,  and,  finally,   to  show 
what  can  be  done  even  in  a  limited  time  to  prepare  a  patient 
for  tali za tion. 

Problems  ^irlsinr  Irior  to  fiosaitali zation 

AS  a  result  of  this  study,  two  factors  emerged  around 
which  the  prol  i-..  .-  -..i  j.  _.  .i  '  e-hospital  planning 

period  clustered.     The  first  coverea  problems  with  which  con 


Crete  practical  help  waa  jiven,   such  as  financial,   claim  fil-  'i 
in:_,  c      agency  referrals.    And  probleics  of  an  eii;otional  or 
psychological  nature  arose  in  which  help  was  limited  because 
of  the  pressure  of  time,  briefness  of  contact,  and  nature  of 
the  illness.     The  proLl..  s  that  arose  most  fre-juently  in  this 
study  were  financial  problems,  interpretation  to  the  families 

'i 

in  addition  to  providin£  emotional  and  economic  support, 
housing  problems,   cle.im  filing;,  alcoholism,   lu  audition  to 
personality  difficulties.     Cther  problems  arose  but  not  to 
such  an  extent  that  would  bear  any  wei;_ht  in  this  studj''.  They 
involvdd  sucii  aii...  LLoit;  t-.s  secur;.a^  trc.nSi>OJ:  tc.t  x  Ju  to  the  hos- 
pital, acquiring  a  medical  statement  for  agency  help,  also  in-  i 
formation  as  to  vfhere  "contacts"  could  be  x-rr.yed.  ' 

The  V y t e r-an  presents  to  the  pr<i-uoai>iLcvj.  ^ luuniUf^  social 
worker  not  only  the  fact  of  illness  but  problems  related  to 
other  areas  of  livin';^  as  well  which  must  be  handled  in  order 
to  facilitate  ciospitali^ation  towards  a  successful  hospital 
discharge.     In  li^ht  of  this,  aa  attempt  will  be  made  to  sort 
out  th.=  se  are-:P  vnd  des-l   v:'t'n  the-n  separately.     Hence,  a  vet- 
eran appear  iii  more  than  one  ^roup.     This  Vias  been  done  in 
order  to  point  out  the  complexity  and  frequency  of  the  problems 
and  to  p.''Ov/  'iow  t'rey  ■  r^e  ^-nr-led  individually  by  the  pre- 
hospital plaiUiint;  social  v/ori.er. 

Attitude  Toward  Illness 

One  veter&r  denied  cTjy  ne-:  f'^-   social  service  assistance 


in  the  pre-hospltal  interview.    He  displayed  a  tood  under- 
stsn-lin"  of  his  illness  and  had  worked  as  an  orderly  in  hos- 
pitals.    .(Qen  hospitalized  his  adjustment  was  poor  primarily 
because  he  had  not  accepted  the  diagnosis  of  tuberculosis  and 
hec    lot   :lven  himself  a  chance  to  AorK  out  soine  of  his  feel- 
ings Ml ior  to  hospitalization.    He  had  a  strong  need  to  oe 
independent  and  self-sufficient,  and  illness  to  him  was  a  sign 
of  weakness.     He  continually  compared  himself  to  other  pa- 
tients worse  off  than  himself  and  belittled  treatment. 

Another  married  veteran  had  many  real  problems  in  plan- 
nin.^  involving    ti.i  financial  care  of  his  family,   their  poor 
housing  conditions,  and  worry  over  a  pregnant  wife.     Prior  to 
hospitalization  he  displayed  competence  and  intelligence  in 
planning  but  did  not  verbalize  any  feeli.ij:_b  .av^un^  his  ill- 
ness.    iVhile  hospitalized  the  social  worker  in  the  Regional 
Office  continued  service  to  his  family,   who  cooperated  to  the 
utmost  in  keeping  troubles  from  the  ve t^^i-.^.. .  ^urir:.^ 

hospitalization  he  could  not  adjust  and  seemed  to  project  his 
own  fears  onto  ais  anxiety  for  his  farriily.     He  would  not  ac- 
cept help  in  understan .  ii:.^  ait  illnssci  .       left  the  hospital 
pleading  financial  difficulties  at  home. 

Of  the  sixteen  veterans  who  were  referred  for  planning 
on  an  initial  diagnosis  of  tuberculosis,  there  were  many  vari- 
eties of  emotional  reactions,        total  of  nine  patients  in 
this  'froup  were  -able  to  verbalize  their  feelings  stemming 


41 

'I 
I 

from  severe  emotional  shock  to  mild,  feelings  of  anxiety. 

'-  t        this  £.roup  completed  hosoitc.l  treatment  £.nd  one  fail 
to  ittuiii  from  a  weekend  pass,   which  was  felt  to  be  his  way 
of  expressing  his  negative  attitudes  toward  treatment.     Three  i 
of  the  sixteen  veteiaiis  displayed  a  fcood  intellectual  under- 
staQQint  during  pre-hospital  planning.     Two  were  discharged 
following  alcoholic  incidents  and  one  because  of  his  attitude 
toward  his  illness.     Four  veterans  expressed  no  feelings  in 
regard  to  illness  or  hospitalization.     Cf  this  group,  one  had 
a  mature  and  independent  personality  and  an  ability  to  make  II 
adjustments.     Cf  the  other  three,   one  was  extremely  nervous 
and  a  wanderer  all  his  life,   one  was  alcoholic,  and  one  had 
difficulty  accepting  his  illness.     These  latter  veterans  were 
irregularly  discharged.  | 

In  the  group  of  eleven  veterans  with  previous  histories 
of  tuberculosis,   ei£ht  were  cases  of  reactivation.     The  ad-  ' 
Justn.ent  of  two  of  the  eleven  cases  via^s  uruvnown.     Five  of 
these  veterans  displayed  in  the  hospital  planning  period  both  ij 
an  emotional  end  intellectual  understanding  of  their  illness 
and  were  -.ule  to  discuss  t.-elr  feedings  in  regard  to  break- 
down.    Four  from  this  latter  group  completed  treatment  and  one  ij 
was  still  hospitalized.     The  last  four  veterans  of  the  total 
group  of  eleven  founo  it   difficult  to  express  their  anxiety 
and  limited  their  participation  in  the  pre-hospital  interview 
to  financial  problems  and  claim  foj  low-up.     Luring.  hospitalizaJ 


I 

\  42 


-  ii 

tlon  these  four  veterans  did  not  complete  treatment  and  dis- 
played attitudes  which  wer^  "    .■Icatlve  of  Icnc-term  inal;L]ity 
to  accept  their  illness. 

Al  coho]  i  SDi 

Those  veterans  who  indulge^.   ...  the  habit  of  driiULlii^ 
alcoholic  beverages  to  excess  were  extre;£iely  difficult  to  spot  jj 
in  the  pre-hospital  planning  period.     In  this  study,   only  one 
such  veter'-i."'^  ="..?Tlttrn   t'  clrl  nking,   but  he  did  not  consider  it 
a  problem  with  whloa  he  neeoed  help.     His  adjustment  to  hos-  jj 
pitalization  w&.s  very  good  until  he  was  involved  in  a  drink- 
ing episode,  anc     e  l  ift   t'i-?  r^ospital  when  advised  that  dis- 
ciplinary action  would  be  taxen. 

During  hospitalization  three  other  veterans  were  involved 
* drinking  episodes  and  also  left  the  hospital.     There  was 
in  both  hospitals  used, for  this  study  a  small  Alcoholics 
Anonymous  group,   but  none  of  these  four  patients  felt  that 
they  needed  this  kind  of  help.     .  .-e  veteran  did  seek  assistance 
during  hospitalization  but  had  wot   indicated  any  need  during 
the  period  prior  to  hospitalization. 

In  the  :re-ho?:'t    1    •;lanning  perlou  where  a  problem  of  I 
this  nature  is  suspected  or  arises,   every  means  is  used  to  of- 
fer  help  in  this  area.     However,         jlcoholic  cannot  be  helped 
unless  he  recognizes  the  need  foi   help  and  wants  to  do  some- 
thing about  his  problem.     In  this  study  the  problem  of  drink- 
ing did  not  seen:  to  be  widespread.     It  was  interesting  to  note 


that  of  the  four  cases  involved  in  drinking  episoces  all  but 
one  veteran  had  beea  making  a  cood  hospital  adjustment  up  to 
the  time  of  the  drinking;  episode. 

Filinp;  a  Claim 
In  this  study,   only  seven  veterans  were  service  con- 
nected at  the  time  of  referral.     One  veteran  had  already  filed  |j 

II 

a  claim  for  a  pension,  and  one  veteran  received  compensation 
for  a  disability  other  than  tuberculosis.     The  balance  of 
eighteen  veterans  was  referred  during  the  pre-hospital  plan- 
ning period  to  file  claims  for  tuberculosis.     This  necessi- 
tated interpretation  by  the  social  v/orker  to  each  veteran  of 
the  benefits  accrued  if  a  claim  was  adjudicated  in  his  favor. 
This  can  be  an  important  aspect  of  planning  from  the  point  of 
view  of  supplement lij^_   lucolU^  w..ore  there  is  financial  dis- 
tress.    During  hospitalization  no  problems  were  noted  in  re- 
gard to  claii:   follow-up  except  in  the  case  of  one  veteran  who 
was  aiixlous  cibout  the  progress  of  his  claim. 

Financial  irroolems 
The  most  frequent  problem  arising  during  pre-hospital 
planning  was  that  of  f inane l.c'.i  need,     .^liriost  half  of  the  vet- 
erans referred  for  hospitalization  needed  financial  assistance  jj 
for  theaiselves  and  their  families.     In  several  cases,  m-arried 
veterans  wei-o  referred  to  commuiiity  agencies  to  irib,Ae  plans  for 
the  support  of  their  families  while  they  were  undergoing  treat- 
ment.    In  one  case,   the  social  worker  had  to  interpret  a  vet- 


eran's  condition  to  a.  local  arency  as  they  did  not  understand 
why  he  coul."  not  continue  ./^rV.  until  he  ivas  adiiiitted  to  t'r.e 
hospital.     In  the  cases  of  sia^^le,   separated,   or  civorced  vet- 
erans livins-  alone,   seven  veterans  were  in  need  of  financial 
support  pendin£  hospitalization. 

During  hospitalization  five  veterans  raised  problems  of 

jj    a  financial  nature.     Three  were  married  veterar^s  concerned 
over  the  welfare  of  their  families,  but  in  these  cases  it  v;as 
felt  that  their  anxiety  was  mainly  a  result  of  their  inability 
to  make  a  good  hospital  adjustment.     'dhen  follow-up  was  made 
it   .^as  ciscovered  that  the  families  were  managing  adeq.uately 
and  had  communicated  this  to  the  veterans  during  their  visits 
to  the  hospital.     In  the  cases  of  single  veterans,  only  two 
showed  concern  d.bout  finances  during  hospitalization.     One  re- 
quest wt.s  unrealistic,  and  it  was  felt  that  he  was  usint^  it 
as  an  excuse  to  secure  a  week-end  pass  as  he  refused  any  so- 
ciaj   service  assistance  and  had      daughter  who  could  have 
easily  handled  the  matter.     The  second  veteran  hs.d  no  finan- 
cial problems  on  hospital  referral  c.s  an  only  relative,  an 
uncle,   was  helping  nim.     rui  ins,  hospitalization  this  uncle 
died  and  arrangements  were  made  through  the  hospital  social 
worker  for  a  small  apjount  of  spending  money  to  be  given  to 
the  veteran  each  month. 

jj  Housing  Problems 

In  two  cases,   the  social  worker  was  active  in  the  pre- 


hospital  planning  period  in  helping  veterans  secure  better 
housin-  for  their  families.     Both  of  these  veterans  lived  in  ■! 
slum  areas  and  had  larg.e  families.     One  veteran  lived  with  his  'i 
wife  and  four  small  children  in  a  condemned  house  with  no 
plumbing  or  heat.     To  have  to  return  to  the  same  environment 
would  have  been  hazardous  to  the  veteran's  health,  plus  the 
effect  of  the  unhealthy  living,  conditions  on  his  family.     Both 'I 
of  these  veterans  expressed  concern  in  this  area  during,  hos- 
pitalization,  out  through  the  combined  efforts  of  the  re- 
gional Office  social  worker  and  the  hospital  social  worker 
the  worry  and  _-xct>cux=  to  return  home  were  lessened. 

Interpretation  to  apd  Sux)port  of  Faiiilies 
The  social  worker  is  responsible  during  the  pre-hospital 
planning  perio_.  lu  giving  ixit erpretation  to  families  of  vet- 
erans and  in  helping  with  any  problems  that  may  delay  the  vet- 
eran's entry  into  the  hospital.     In  seven  of  the  cases  studied,  I 
the  social  worker  was  active  in  ti.is  resi^ect.     In  one  case,  th^ 
veteran  would  not  accept  hospitalization  at  the  Rutland  Vet- 
erans Administration  Hospital  where  beds  were  available  and 
woul5  only  go  to  Gushing  Veterans  ittdiiilnistrat ion  Ho8.:-ital 
rhere  there  was  a  long  waiting  list.    He  would  give  no  reason  jj 
for  this  but  was  adamant  in  his  attitude.     The  veteran's  wife 
was  contacted,  and  it  was  learned  thctt  the  veteran  thought  he 
was  being  referred  to  the  public  sanatorium,   which  is  also  lo- 
cated in  Rutland,   ar.d  was  being  rejectee  by  the  Veterans  ^.d- 


ministration.     Follow-up  was  important  beca-use  any  undue  de- 
lay in  hospitalization  mitht  have  been  detrimental  to  the 
veteran' s  health. 

Another  veteran  was  accompanied  to  the  Chest  Clinic  by 
his  wife  who  was  interviewed  by  the  social  worker  while  he 
was  exciiuined  by  the  doctor.     The  wife  was  emotionally  over- 
wrought at  her  husband's  reactivated  condition  but  was  un- 
accepting  of  any  help,   thou£h  obviously  in  need  of  emotional 
support.     She,   herself,  had  a  tubercular  condition  and  many 
anxieties  around  her  own  illness  and  had  oeen  discharged  ir- 
regularly from  a  ruhlic  sanatorium.     In  this  case,   the  vet- 
eran and  his  wife  were  so  upset  they  would  not  stay  more  than 
five  minutes  in  the  social  worker's  office,  feelinj  they  could 
handle  their  own  problems.     ,;hen  finally  admitted  to  the  hos- 
pital he  left  fifteen  days  later. 

In  another  situation  where  there  was  a  language  handi- 
cap,  the  social   worker  v/as  active  in  enlisting  the  encourage- 
ment of  an  uncle  of  the  veteran  to  plan  for  medical  treatment. 
Since  both  the  uncle  and  the  veteran  were  fairly  new  to  this 
country,   the  social  worker  was  able  to  assist  the-'   Vj  practi- 
cal planning,  to  interpret  the  doctor '  s  recomu^endat ions,  and 
to  help  theiu  to  ^ork  through  some  of  their  anxieties. 

In  three  cases  of  married  veterans,   the  worker  a. s  active 
in  giving  emotional  support  and  encouragement  as  well  as  help 
in  practical  planning  to  the  wives  of  veterans.     In  these 


cases, the  social  worker  continued  her  relationship  with  the 
wives,  and  it  was  f^lt  that   she  was  instrumental  in  making  i| 
it  possible  for  the  vet era us  to  ucuefit  from  treatment.  | 

Personality  Problems  ! 

In  cases  where  the  '  a in  problem  seenied  to  be  the  vet- 
eran's personality  which  aleitea  tcie  social  worker  to  ^ossiole 
inability  to  complete  long-term  treatment,   it  was  not  possible 
for  the  social  worker  to  hyn^le  t^"*  °>  as  effectively  as  ini-vht 
have  been  done  had  there  beeu  uor^  time  available.     In  six 
of  the  cases  studied,  the  recording  on  the  cases  indicated 
that  in  view  of  the  Vetera  '3  personality,  adjustment  to  hos-  i 
pitalization  might  be  difficult.     In  one  case,  the  veteran  came 
to  the  social  service  interview  accompanied  with  his  power-of- 
attorney  in  order  to  apply  pressure  to  be  adinitted  to  the  hos- 
pital on  an  emergency  basis.    He  had  many  negative  attitudes 
toward  the  Veterans  Administration  and  felt  people  shunned  him 
because  of  his  illness.    However,  this  veteran  did  complete 
treatment.     This  could  probably  be  explained  by  his  youth  and 
aggressive  desire  to  overcome  his  illness,  which  was  strong 
enough  to  keep  him  in  the  hospital.     This  can  only  be  assumed 
since  this  is  one  of  the  ca,ses  where  material  of  hospital 
adjustment  was  not  available. 

In  two  cases,   the  veterans  had  been  hospitalized  in  the 
past  for  nervous  breakdowns.     One  veteran's  condition  was  di- 
agnosed as  psychoneurosis,  moderately  severe,  anxiety  state. 


and  the  other  Just  as  "nervous  breakdown."     Chronic  anxiety 
state  v^y-s  the    .  i  r;.!__.iOb 1 1>  .  iven  to  another  veteran  durin^^  hos- 
pitalization.    Cf  the  remaining  two  veterans,   one  was  an  al- 
coholic and  the  other  showed  a  paranoic  tendency.    ^11  but  one 
of  th3se  six  cases  with  personality  difficulties  were  irregu- 
larly discharged  from  the  hospital. 


CHAPTER  V  I 

I 

DESCRIPTION  OF  VETSRh:I3  STUDIED  | 
The  primary  basis  for  the  choice  of  the  twenty-seven  case^ 
used  in  this  study  was  referral  for  hospitalization  on  the 
first  diagnosis  of  tuberculosis  at  the  Boston  Regional  Office  | 
Chest  Clinic.     For  purposes  of  further  clarification  of  the 
previous  statement,  fourteen  veterans  had  had  tuberculosis 
previously:     one  treated  by  a  private  doctor  for  a  two  month  ^ 
period,  two  hospitalized  more  than  ten  years  ago,  and  the  I 
balance  of  ten  veterans  were  hospitalized  within  the  past  five 
years . 

The  majority  of  the  veterans  served  in  World  iifar  II.  Two 
veterans  served  during  the  Korean  iVar,  and  four  served  during 
World  V/ar  I. 

Age 

The  ages  of  the  twenty-seven  veterans  studied  ranged  from 
twenty-one  to  sixty  years  as  illustrated  in  Table  I.  Eighty- 
one  per  cent  of  the  twenty-seven  veterans  studied  were  in  the 
socially  productive  age  group  described  in  the  previous  chap- 
ter as  between  fifteen  to  forty-five  years  of  age.  Nineteen 
per  cent  of  the  cases  were  in  the  older  age  group.     These  find- 
ings correlated  with  the  general  knowledge  that  tuberculosis 
is  more  prominent  in  the  younger  age  groups. 

In  the  socially  productive  age  group,  where  discharges 
were  known,  60  per  cent  of  the  veterans  were  regularlv  dis- 


charged  upon  completion  of  medical  treatment  and  40  per  cent 
received  irregular  discharges . 

among  those  veterans  regularly  discharged,  96  per  cent 
were  between  the  ages  of  twenty-one  and  forty-four,  and,  in 
those  irregularly  discharged,  73  per  cent  were  between  the 

I 

ages  of  twenty-eight  and  forty-five.     This  seemed  to  suggest 
that  those  veteri%ns  benefiting  from  medical  treatment  were  of 
a  slightly  younger  age  group  than  those  studied  who  did  not 
complete  treatment. 


TABLE  I 

AGES  CF  ViTErlAAO  5TZ  ^l^u 


Ages 

21  — 

23 

3 

11.1 

24  — 

26 

1 

3.7 

27  -- 

29 

5 

18.5 

30  — 

32 

2 

7.4 

33  — 

35 

1 

3.7 

36  — 

36 

2 

7.4 

■^Q  -- 

41 

1 

3.7 

42  — 

44 

c 

15.5 

45  — 

47 

2 

7.4 

48  — 

50 

0 

0.0 

51  — 

53 

3 

11.1 

54  — 

56 

1 

3.7 

57  — 

59 

G 

0.0 

60 

1 

3.7 

Total 

27 

99.9 

Marital  Status 

Amon^  the  twenty-seven  veterans  studied  approximately  40 
per  cent  were  married  and  the  balance  were  single,  divorced, 
or  separated  (see  Table  II ).     Of  the  ten  veterans  married  five 
completed  hospital  treatment,  one  was  still  in  the  hospital 
at  the  time  of  this  study,  and  four  did  not  complete  treatment. 

In  the  majority  of  cases  tha  Tarital  relationships  were 
harmonious,  and  in  only  one  of  the  cases  was  the  nature  of  the 
marital  relationship  considered  to  interfere  in  pre-hospital 
rjlannlnr  for  adjustment.     In  this  particular  case,   the  wife 
of  a  veteran  was  extremely  upset  over  the  need  to  have  her  hus- 
band hospitalized  for  tuberculosis.     Both  the  veteran  and  his 
wife  refused  any  help  as  they  were  very  close  to  each  other 
and  wished  to  work  out  their  own  problems.     Three  months  after 
the  initial  hospital  referral,  the  veteran  was  admitted  to  the 
hospital  but  left  fifteen  days  later.     His  strong  dependent 
relationship  to  his  wife,  fear  of  separation  from  her,  and  her 
refusal  to  face  the  need  for  hospitalization,   seemed  to  be 
factors  that  interfered  with  the  veteran's  ability  to  adjust 
to  and  complete  treatment.     This  seemed  to  be  supported  by 
his  previous  history  of  irregular  discharge. 

Among  those  veterans  divorced  and  separated,   in  most 
instances  they  were  not  responsible  for  the  support  of  chilarer, 


BOSTON  UNIVERSITY 
SCHOOL  OF  SOCIAL  WORK 
LIBRARY 


TaBLZ  II 

Marital  status  of  vetepiaats  studied 


status  at  Hospital 
Referral 

Number 

Per  Cent 

Single 

10 

37 .0 

Separated 

1 

3.7 

Divorced 

5 

18.5 

Married 

n 

4C.7 

Total 

99 » ^ 

Occupations 

Prior  to  Hospitalization 

That  tuberculosis  strikes  persons  in  all  walks  of  life 
is  widely  shown  in  reseach  reports  as  well  as  by  the  variety 
of  occupations  held  by  those  veterans  studied  here.     Of  the 
total  number  of  veterans  studied,  their  occupations  were  classi- 
fied in  the  following  manner:     one  student,  fifteen  unskilled 
workers,  five  skilled  workers,  four  professional  persons,  and 
two  occupations  miknown.     Some  of  the  occupations  given  are 
as  follows:     factory  worker,   stock  clerk,  gateman  for  sewer 
department,  laborer,   cafe  owner,  textile  worker,  electrical 
worker,  orderly,   street  cleaner,  truck  driver,   school  teacher, 
industrial  instructor  at  a  reformatory,  organist,  garage 
mechanic,   carpenter,   salesmarj,   clerk-typist,  and  metal  finisher. 

Finances 

In  the  pre-hospital  planning  period  it  was  significant  to 

note  that  in  those  cases  studied  approximately  59  per  cent  of 
the  veterans  had  no  financial  problems.     In  many  instances. 


veterans  were  receiving  disability  compensation  from  the  Vet- 
erans Administration;  in  the  majority  of  these  cases  had  there 
not  been  any  compensation  from  the  government,   there  would 
definitely  have  been  a  larger  percentav^e  in  need  of  financial 
assistance.    As  it  was,  however,  almost  41  per  cent  did  need 
planijing  in  the  financial  area  for  the  support  of  families  and  j 
dependents.     Several  of  the  veterans  who  were  entirely  on  their*] 
own  were  in  need  of  emergency  financial  aid  pending  hospitali- 
zation.    During  the  hospitalizat ion  j^eriod,   only  one  unmarried 
veteran  was  in  need  of  financial  assistance,  and  his  need  was 
not  present  at  the  time  of  pre-hospital  planning  but  arose  due 
to  the  death  of  any  uncle  who  had  been  helping  hira. 

Another  single  veteran  raised  a  financial  problem,  concern- 
ing a  car  he  had  left  in  an  empty  lot.     Realistically,  this 
car  had  been  left  to  the  ravages  of  the  previous  winter  with- 
out any  apparent  concern,  and  in  view  of  the  fact  that  the 
veteran  refused  social  service  help  in  both  the  pre-hospital 
and  hospital  periods,  his  problem  was  not  considered  a  realis- 
tic one . 

In  the  four  cases  of  married  veterans  that  had  real  finan- 
cial problems  during  hospitalization,   everything  possible  had 
been  done  prior  to  hospitalization.     The  hospital  social  worker 
was  active  in  a  supx:orting  way  and  f-ave  encouraji-ement  and  reli^ 
to  those  veterans  who,   basically,   had  made  a  good  adjustment 
but  were  concerned  about  their  families. 


Of  eleven  veterans  studied  who  had  financial  problems 
prior  to  hospitalization,   only  six  raised  financial  problems 
during-  hospitalization. 

TABLS  III 

F I NAFGIAL  STaTUS  OF  VETERaNS  STUDIED  PRIOR  TO  HOSFITiiLI ZaTION 
Marital  Status  Adequate  Inadequate 

Married  7  4 

Single  6  4 

Divorced  3  2 

Separated  0  1 

Total  16-59.2  j]   -  4C.8 

Referral  for  Hospitalization 
Actual  referral  for  hospitalization  in  the  cases  studied 
showed  that  one-third  of  the  twenty-seven  veterans  were  in 
need  of  emertfency  hospitalization.     In  several  cases,  they 
were  adraitted  to  the  hospital  on  the  same  day  or  wltnin  two  or 
three  days  following  referral.-    Emereency  hospitalization  was 
recommended  for  both  medical  and  social  reasons  in  nine  cases. 
In  seven  cases  medical  emergency  was  noted  and  in  the  remain- 
ing two  cases,   social  emergencies.     In  eighteen  cases  hospi- 
talization was  required  with  routine  hospitalization  procedures 
followed.     Social  emergency  was  usually  involved  when  there 
was  any  possibility  of  infecting  other  family  members,  espe- 
cially small  children  in  the  same  home  as  the  veteran.     On  the 
other  hand,  medical  emergency  was  involved  where  immediate 


medical  attention  was  required. 

The  usual  time  between  referral  for  hospitalization  and 
actual  hospital  admission  varied  from  one  day  to  one  hundred 
and  eighty-seven  days  with  an  averaefe  waiting  period  of  t /fenty- 
seven  days.    Many  factors  were  responsible  for  this,  and  the 
major  factor  seemed  to  be  the  Ion;;    waiting;  list  for  hospitali- 
zation durina  the  year  1951*     oiuce  thi;it  tiiae,  however,  refer- 
rals for  hospitalization  under  a  new  Veterans  iidminist rat  ion 
ruling  must  be  admitted  to  a  hospital  within  ten  days. 

Of  the  cases  studied  and  referred  for  hospitalization  in 
1951>  only  seven  were  service  connected  and,  as  such,  had 
priority  on  the  hospital  waiting  list.     ««hether  there  is  any 
real  meaning  from  the  psychological  point  of  view  between  the 
length  of  time  from  referral  to  hospital  admission,  it  is  dif- 
ficult to  determine. 

Types  of  Hospital  Discharges  of  Veterans  Studied 


TABLE  IV 

HOSFIThL  discharges  of  V2TERiioJS  STU'DIiiD 


Type 

Number 

rer  Cent 

Regular 

13 

48.2 

Irre-^ular 

11 

40.7 

Still  Hospitalized 

1 

3.7 

Unknown 

7.4 

Total 

^  -7 

c-  [ 

ICO.O 

Of  the  twenty-seven  veterans  studied,  thirteen 

were  dis- 

charged with  maximum 

hospital  benefit  or,  as  in  one 

ease,  with 

no  treatment  required.     Of  the  balance,   except  for  two  unknown 
and  one  still  hospitalized,   they  were  irregularly  discharged. 

! 

i! 

In  no  instance  did  their  reasoning  for  obtaining  an  irregular  I: 
discharge  focus  on  the  lack  of  social  service  help  with  con- 
crete practical  problems  in  the  pre-hoscital  planning  period. 
In  the  majority  of  cascs  tne  xcasons  Sctiuied  to  be  sii:nif Icantly 
related  to  the  meaning  of  the  illness  to  each  individual 
patient.     It  seemed  probable  that  these  veterans'   total  needs 
wei'S  Liot  .uct  Q,Q.B^uc.t^1j  durliii^  the  pre-nOb^' itc;.!     ld.i.iuiuj-_  lod 
The  limits  of  time,  personality,  and  attitudes  were  mainly 
responsible  for  this  inability  to  meet  their  total  needs. 
However,   from  this  study  in  relation  to  irregular  discharges, 
it  seemed  that  a  stronger  liaison  relationshi];^  insuring  con- 
tinuous casework,  between  the  pre-hospital  planning  social 
worker  ana  tne  hospital  social  worker  might  have  inabled  many 
of  these  veterans  to  complete  hospital  treatment.     In  all 
cases  their  irregular  discharges  seemed  to  be  rjreci  pitated  by 
long-term  inability  to  adjust  to  their  illness  and  hosp j.t<a.iiza- 
tion  and  to  personality  difficulties. 

Of  the  thirteen  veterans  with  regular  discharges,   six  had 
been  previously  hospitalized  for  tuoercuios is,  and  of  tne  elsvoiL 
irregularly  discharged,   four  had  been  previously  hospitalized 
for   tuberculosis.     Of  the  other  three  veterans  with  a  previous 
history  of  tubt:rculosis,   the  type  of  ^iscuarge  of  two  is  un- 
known and  one  is  still  hospitalized.     There  seems  to  be  a 


57 


slightly  higher  proportion  of  veterans  with  a  previous  history 
of  tuberculosis  benefiting  from  later  hospitalizations. 


CHAPTER  VI 
SUl^mRY  AND  CONCLUSIONS 

The  purpose  of  triis  study  of  twenty-seven  tuberculous 
Veterans  referred  for  pre-hospital  planning  from  the  chest 
Clinic  of  the  Boston  Regional  Office,  Veterans  Administration, 
to  social  service  was  to  discover  the  types  of  problems  that 
arose  during  the  pre-hospital  period  and  how  the  handling  of 
them  affected  hospital  adjustment. 

A  description  of  the  Chest  Clinic  and  the  functions  of 
the  social  worker  were  given.     Current  literature  was  pre- 
sented in  order  to  give  a  background  to  the  study. 

A  description  of  the  veterans  studied  was  given,  al- 
though ages  ranged  from  twenty  to  sixty,   the  majority  of  vet- 
erans were  in  the  socially  i-ro:iuctive  age  group  (fifteen  to 
forty-three).     The  study  seemed  to  indicate  that  those  vet- 
erans benefiting  from  hospital  treatment  were  of  a  slightly 
younger  ,__rou^  tact.,  tuobc    ,ot  couipleting  treatment.  In 

almost  all  of  the  eleven  cases  of  ms^rried  veterans  studied, 
the  marital  partners  seemed  to  cooperate  in  treatment  planning 
and  marital  problems  were  not  seen  as  an  important  factor  in 
this  study,   except  in  one  case.     The  variety  in  occupations 
tallied  with  current  research  that  tuberculosis  strikes  per- 
sons on  all  socio-economic  levels,     .ilitiost  half  of  the  vet- 
erans studied  had  financial  proolems  which  were  adequately 
handled  prior  to  hospitalization,   except  for  one  case.  In 


this  ciise,  the  need  was  aot  present  at  the  time  Ox^  referral. 
In  nine  cases,  the  veterans  were  referred  for   eiLergency  hos- 
pitalization, putting  an  added  pressure  on  the  Job  of  the 
social  worker.     A  little  less  than  half  of  the  vetera.js  stud- 
ied received  regular  discharges. 

Seven  samples  of  case  summaries  were  presented  in  order 
to  show  more  clearly  the  variety  of  problems  that  arose  dur- 
ing the  pr^i-hospi tal  period  and  how  the  handling  of  these  prob- 
lems affected  hospital  -  adjustment .     The  most  common  problems 
arising  in  the  pre-hospital  planning  period  centered  around 
the  givin.^  of  concrete  _,i  cyclical  help,   such  as  in  financial 
planninj,  claim  filing,  referral  to  agencies,  housing  problems,! 
alcoholism,   interpretation  to  and  support  of  families,  the 
handling  of  t\\e  e:notional  shock  of  diagnosis  z^ai  acceptance 
of  illness,  and  personality  problems. 

There  was  a  tendency  for  most  of  the  veterans  who  were 
able  to  face  ano  accept  trielr  ilj.ness        the  tliLe  of  diagnosis 
to  complete  hospital  treatment.     However,   in  a  few  cases  there 
were  some  who  seemed  to  fdce  f'eir  problems  at  first  but  later 
after  hospitalization  showed  dibturbance .     .ilso,   in  this  study, | 
those  veterans  with  reactivated  conditions  who  showed  accept- 
ance of  their  illness.  _rior  to  hospitalization  seemed  to  com- 
plete treatment.     Ihis  mi_ht  ci.lso  be  explained  by  previous 
hospital  experience.  ' 

Although  the  jr-^^^ler  of  alcoholism       g  not  aii  exceptional- 


ly  widespread  one  in  this  study,   it  does  present  a  serious  : 
problem  to  hospital  treatment.     An  Interesting:  obser  v^^.t  i  on  was 
made  as  a  result  of  this  study,   that  up  until  the  time  those 
veterans  with  this  problem  indulged  in  drinking  they  hc^d  been  i 
making  ^  _ood  hospital  adjustment.  I 

Claim  filin.    is  an  important  c^spect  of  pre-hospital  plan-  j 
nine:.     It  lets  the  veterans  know  thc-.t  his  ri£.hts  are  being 
considered  as  well  as  providing  him  with  financial  assistance. 
Almost  all  of  the  veterans  studied  were  referred  to  file  a 
claim  for  service  connection.  ij 

The  financial  _ roblems  that  emerged  in  this  study  were 
'generally  concerned  with  referral  to  a  coiWiunity  agency. 
Financial  problems  were  evident  in  almost  half  of  the  cases  I 
referred,  cu.d  the  percentage  would  have  been  higher  except  for 
those  veterans  already  havin-'  disability  pensions.  j 

Althou.h  only  two  cases  arose  concernin-:  housing  prob- 

I 

lems,   they  were  imxjor  tant  as  tue^   ^x^  dutcc   ti.e  veteris-.is' 

ability  to  adjust  to  hospitalization  because  of  worry  over  their: 

j 

fa-iiiv.     It  was  almost  as  important  from  lonc--range  planning  i 

I 

to  Letter  the  livin,^   conJltions   '      ..ilcii  th^  veteran  would 
have  to  return  on  the  completion  of  treatment.  || 
The  importance  of     ivint^  emotional  support  to  families, 

j 

of  interpreting.  illnc;ss  to  fa^iiia-ies,  of  ^-  1.^  practi- 

cal planning  during  the  veteran's  absence  were  significant 
factors  in  facil '  t  ,  ^  '         ospitalization  and  hospital  adjustment! 


61 


V/here  there  was  a  sever-e  or  mental  g  isturbarjce  in  ad- 
-■^it'on  to  illness,   f^ie  najorlty  of  veter^--  q  ■"I'j  i^iot  comr.l'fte 
tree-tment .     It  seeiue  though  mental 

a;;ainst  successful  hospitalization. 

Because  of  the  pressure  of  t         "rirlrj  ^'  the  ore-hospital 
planning;  peiioc,   it  was  felt  this.t  tue  eff cc t ivuaess  of  the  [ 

social  worker's  ability  to  deal  with  emotional  problems  was  ^ 

1 

limited.     However,   there  is  no  doubt         t  ">  t  .     importance  of  ' 
this  phase  of  treatment.     The  social  woriiLer's  aiain  responsi- 
bility seejis  to  be  that  of  facilitating;  medical  treatment  by 
helping  the  veteran  overcome  the  -■-'i-'  :  '^   shock  of  illness  to  ; 
such  an  extent  that  he  will  accept  and  move  toward  hospitali-  | 
zation.  I 

T:.:.  ....Jorlty        -v.'^vl.:..o  _     .onfro  :t       .  ux  i-^  the 

hospital  period  in  this  study  were  evident  durint  the  pre- 
hospital period.     During  hospitalization  no  real  problems  j 
:  rose  in  the  sooio-econoiiiic  area  ^^roblems  had  been 

handled  ade-iuately  during  the  pre-hospital  planning  period.  | 
Problems  that  -^id  arise  jurinr  hospitalization  seemed  to  be 
of  ir..,     ..ot iona..  zi  ^- s/ cholo^ .1.  Cu. X  .j..  Lu^c:  iLicc^llity  to  o.c- 

cept  illness.  j 

It  ',^^oul^.   see^'  to  be  Inolcated  th&t   thou  h  the  social  j 

t 

wGir.^i   cfeiii'Ot  ■         ..rior  t v,-  ujo^:  1  ciLj.izal  lorj.  expect  to  j 

.  successfully  problems  other  those  of  a  practical 

nature,   she  must  be  cograzant  of  the  extent  of  emotional  prob- 


62 

i 

Isms,  attltulies,  -  laladjust ed  personalities.     She  must  be 

i.'-l     t-  v-.iuations  in       V'^i-.f       :  ''•c         tl:!:e.     To  i  lan  ' 

ost  ef  I  actively  for  the  veterfau  she  must  pass  on  this  Informa-j 
tion  to  the  hospital  social  worker,  who  will  be  prepared  to 

responsibility  in  this  area.     This  ^  -  ^  ./ould 
seem  to  indicate  that  it   is  extremely  important  th.-.,t  there  be  j 
a  strong,   sharing,  liaison  relationship  between  the  Chest  [ 
Clinic  soc^...i  vrorkej.  the  hospito.,...  ooc  i--.-  x  worker. 


SCHiLDULE 

^  Name  

ae^e  

Marital  Status   

Number  of  Children  .  .   

Family  Income  ^  

Occupation   

Veterans  Administration  Pensions   

Medical  Diaf;,nosis  Other  Dia£,no3is  

Previous  History  of  Tuberculosis   

Type  of  Hospitu.1  Referral  Reason  

Time  between  Referral  and  Admission  

Type  of  Hospital  Dischar£:e  

Reason  for  Irresular  Dischar-v-e  

Social  and  Emotional  Factors 

3hoc-v  of  Diagnosis  

Attitude  toward  Illness  

Attitude  toward  Hospitalization  ,  

Financial  Problems  and  other  Social  and  Economic  Problems 

arising  during  the  Fre-hospital  Planning  Period  .  .  . 
Social  and  Economic  Problems  arising  during 

Hospitalization  

Emotional  Problems  arising  during  Pre-hospital  Planning.  . 

Emotional  Problems  arising  during  Hospitalization  

Personality  Difficulties  arisinj  durin':  Pre-hospital 

Plannine  •  

Personality  Difficulties  arlsluy  during  nospi tt.lization.  . 


64 


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Robinson,   Canby  G.,  The  Patient  .^i:;  ...  xerson.  New  York:  The 
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U p ham ,  Francis,  tx  Dynamic  Approach  to  Illness — h.  Social  rt'ork 
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0^ 


i 


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BOSTON  UNIVERSITY 


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